#tenncare

A Knoxville dentist has agreed to pay nearly $1 million to resolve allegations of false claims to TennCare, according to a news release from the U.S. Attorney's Office.

Dr. Michael Sawaf and his company, Premier Dental Group of Knoxville on Concord Street, violated the False Claims Act and the Tennessee Medicaid False Claims Act by knowingly and improperly submitting false claims, the release said. TennCare prohibits billing of services that are not provided or are unnecessary, or claims with upcharges to receive higher reimbursements.

Two people who worked with the dental group, Erin Ferdowsi and Reja Ferdowsi, have agreed to resolve similar allegations made against them, the agency said.

The amount Sawaf agreed to pay was $985,541. It covers allegations that between Jan. 1, 2016, through Dec. 31, 2020, and a period of time between Aug. 14 and Sept. 11, 2019, the group submitted claims for payment that misidentified credentialed dentists as the provider for services done by uncredentialed dentists.

Erin Reed at Erin In The Morning Substack: 

In recent months, numerous bills have been introduced that negatively affect transgender individuals. Most of these bills focus on transgender youth and include provisions such as forcing medical detransition, imposing bathroom restrictions in schools, and prohibiting teachers from using preferred pronouns and names. However, there has been a recent surge in bills that target transgender adults. One such bill is HB1215 in Tennessee. The proposed legislation not only prohibits health insurance companies from contracting with TennCare in Tennessee but also prevents them from receiving TennCare contracts if they cover gender-affirming care for any age in any state. On Tuesday, the House Insurance Committee in Tennessee debated the measure, ultimately passing it out of committee on a voice vote.

The bill in its original form stated that any managed care organization that contracts with TennCare, Tennessee’s Medicaid program covering 1.7 million people, from covering gender affirming care. This restriction applied to transgender adults as well. People quickly pointed out that this bill could target insurance companies like Blue Cross Blue Shield and United Healthcare, both of whom administer TennCare programs, from providing gender affirming care coverage for transgender adults. Others pointed out that the bill could even ban companies for providing such care out of state.

On Tuesday, the bill’s sponsor, Representative Tim Rudd (R), put forward an amendment to clarify that the bill’s intent to target insurance companies for any transgender healthcare coverage nationwide. The amendment goes further than what even most activists feared. It bans:

Insurance companies from providing care for trans people nationwide.

Insurance companies with similar trademarks or names from providing that care nationwide.

Insurance companies acting as subsidiaries from providing that care nationwide.

Insurance companies acting under another company’s license from providing that care nationwide.

[...]

This is a major escalation against transgender adults . Should this bill pass, Tennessee will have to drop companies like United Healthcare and Blue Cross Blue Shield, as they provide gender affirming care coverage in many states (and are mandated to by state and federal law). The only way these organizations could contract with Tennessee is if they dropped their gender affirming care coverage for transgender adults in all US states. They are unlikely to do this as Tennessee’s share of the health insurance market is not very large. However, if larger states pass similar legislation, red states could attempt to force insurance coverage to drop gender affirming care coverage for trans adults nationwide.

This bill contradicts US federal law and is flatly unconstitutional. That is what Representative Bo Mitchell (D) stated about the bill. After Democrats argued over the bill’s violations of the commerce clause, ERISA protections, and the Affordable Care Act, he questioned the sponsor about the mechanics of the bill. 

Tennessee HB1215 is a very concerning anti-trans bill due to the fact that TennCare cannot receive contracts from health providers if they provide gender-affirming care anywhere in the USA at any age. 

Will TennCare cover drug rehabilitation? Yes, but it's another story about whether folks who require alcoholism and addiction therapy use those benefits—those covered by TennCare, Tennessee's Medicaid program, experience a double stigma. As a result, many people who might benefit from therapy the most frequently forgo it. That frequently happens because resources are limited, and many Americans who require drug addiction treatment don't receive it. Additionally, addicts and alcoholics frequently lack access to health insurance coverage and disposable cash. Many programs nowadays do not neatly fit into standard categorization for drug addiction treatment due to the ongoing evolution and diversification of treatment methodologies and individual programs. This blog will make an effort to comprehend important details regarding the stigma associated with drug rehabilitation, Tenncare coverage for substance abuse treatment, and those who qualify for this program.

So I had cellulitis (a bad infection) in my jaw/cheek and a giant abscess, under two teeth that had to be pulled out and my bone scraped, from a bad root canal (fun!) that was infected and swelled to the size of a grapefruit making me look like Quasimodo for a week and nearly killing me.

I had to be admitted to the hospital. I have two auto-immune disorders, so infections are a big deal for me.

I can’t take regular anti-biotics due to penicillin allergies, so I have to take Clindamycin. This with pain meds makes me violently nauseous. So I have to take nausea meds every time I take my other meds, each 6 hours.

Thing is, insurance can’t figure out why I need more than 10 Zofran a month, despite the ER doctor prescribing it.

So the oral surgeon can give me as much high dose Phenergan as he wants, which is waaaaay stronger, and knocks me out for 16 hours a day.

Thing is I can’t take my anti-biotics, hydrate, regulate my blood sugar etc if I am ASLEEP!

Plus I’d like to live my life.

I have about 30 more antibiotics left to take. I need nausea meds with every antibiotic.

Insurance, I need Zofran to not puke violently, be awake, and not go into a diabetic coma.

With four months until the end of the calendar year, there are still a large number of Medicaid redeterminations requiring submission in order to ensure the continuation of Medicaid-funded services for persons enrolled in the DIDD waivers.  It is absolutely essential that people, families, providers, ISCs, and DIDD continue to work together to ensure 100 percent completion by the end of the year.

As of the last reporting period, 26 percent of Medicaid Redeterminations have been completed and submitted to Maximus, TennCare’s contractor for Medicaid financial eligibility reviews.  Thank you to everyone involved who has assisted in the submission of these in a timely manner. 

ISC agencies are continuing to communicate with persons, families, and providers to complete a redetermination for everyone who does not currently receive standalone Supplemental Security Income (SSI).  DIDD cannot overstate the importance of completing all outstanding redeterminations.  Failure to submit a fully completed redetermination application to Maximus in a timely manner will result in the person being disenrolled from DIDD waivers, and there is no option for re-admittance to DIDD waivers should a person be disenrolled.

Each ISC agency is required to submit information to the regional offices, including the date completed and date faxed to Maximus by the 10th of each month for review.  Regional and Central Office staff are compiling information submitted and will reach out to ISC agencies for additional information or clarification where necessary.  ISC or Providers who have questions about the process may contact the following persons:

East Regional Office:

Christie Ellis

[email protected]

423-634-2415

 Middle Regional Office:

Lucretia Baxa

[email protected]

615-884-4314

 West Regional Office:

Linda Hall

[email protected]

901-745-7553

 Central Office:

Annette Caldwell Binkley

[email protected]

615-532-3245

 Timothy Hickman

[email protected]