Tennessee Reaches Agreement With Pediatric Group Allegedly Overcharging For TennCare Services

Monday, December 16, 2013

A Memphis pediatric group will pay the State of Tennessee more than $540,000 over five years to settle allegations that the group was overcharging TennCare billings, Attorney General Bob Cooper announced.


The State alleged that Segal, Parker, Kronenberg, Tsiu & Eiseman, L.

L.C. and three of its affiliated pediatricians engaged in what is known as “upcoding,” meaning it billed for doctor’s visits using codes denoting a higher level of service than was actually provided.  Such upcoding results in physicians being paid at higher rates than those to which they are entitled.


The practice group was identified by TennCare’s Office of Program Integrity (OPI) through the use of data analytics.  OPI discovered the over-billings during its normal data analysis. OPI employs complex algorithms designed to sift through massive amounts of TennCare billing data and identify potential billing outliers. A subsequent investigation by the Attorney General’s Office substantiated the claim that significant upcoding was occurring.  There was no evidence of any patient harm in this case.


“TennCare continues its efforts to fight fraud and abuse in the program by using the latest data analytic tools to discover improper behavior,” said TennCare Director Darin Gordon. “This allows us to focus our personnel and resources on those cases that are most likely to involve significant fraud or abuse by Providers.”


The State does not allege that the practice group engaged in an intentional scheme to defraud TennCare.  Rather, TennCare provider fraud is pursued under the Tennessee Medicaid False Claims Act, which allows the state to recover penalties and treble damages against healthcare providers who bill TennCare with “reckless disregard” as to the truth of their billings.


“Reckless acts of overbilling can cost TennCare as much as intentional attempts to defraud the program,” General Cooper stated.  “We will continue to follow through on any suspicious billings referred to the office by the TennCare program.” 

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