Saunders may lead push to curb Medicaid prescription fraud

Legislators will grapple with measures aiming to stem the millions of dollars paid by Medicaid for prescription drugs that get diverted to illegal street use and other fraudulent endeavors.

Fraud occurs when patients "doctor shop" for numerous prescriptions and sell the drugs on the street, when physicians falsify a patient's diagnosis to get fraudulent prescriptions for street sales and a host of other illegal schemes that also can involve clinics and pharmacies.

State Sen. Burt Saunders, R-Naples, through his subcommittee on Medicaid prescription drug fraud, is sponsoring a bill that would broaden the authority of health regulators and the state's Medicaid fraud unit.

The bill could require Medicaid patients to be locked into seeing one provider, require them to get a second opinion before the state authorizes payment for prescriptions and could mandate participation in a drug therapy management program.

From a physician's standpoint, the bill would allow the state to terminate a doctor's participation in Medicaid for inappropriate prescribing, could require a prepayment review of claims and would allow the state to look at a physician's non-Medicaid records to reconcile billing to the state against physicians' total practice activities.

Saunders said getting a handle on Medicaid prescription fraud is his top health-care priority this year. There's agreement among the governor's office, the state Attorney General, the Florida Department of Law Enforcement and the health-care industry to take a tougher stance against the problem, he said.

At the same time, the Florida Medical Association has concerns some of the bill's components would unwittingly hamper physicians' abilities to treat patients or patients' access to medical care.

"We do have some concerns," said Francie Plendl, director of governmental affairs for the association. "One of the things that's in there is a second opinion (rule). We all want to help Medicaid get rid of some of the fraud but there has to be a way to get it out of the system without harming access to care for patients."

Plendl said the association and state regulators are working on ways to reach more common ground.

The continuing financial woes of trauma centers around Florida — including the one at Lee Memorial Hospital near downtown Fort Myers — and the formation of a lobbying alliance of the state's 20 trauma centers has garnered support among legislators wanting to provide help.

The goal of the Alliance to Save Florida's Trauma Care is finding $126 million annually to be divided among the trauma centers by increasing penalities to bad drivers.

One bill would increase penalities for running red lights; another bill creates a driver's responsibility program to impose annual penalties to drivers for various infractions.

For instance, one bill calls for a driver to pay $100 after accumulating six points against his or her license during the previous 36 months and $25 more for each additional point. If convicted of driving under the influence, the offender would pay an additional $1,000 in penalties and $1,500 if it is a second DUI offense.

Bad drivers collectively are responsible for about 50 percent of auto accidents where the victims need trauma care, according to the alliance.

Saunders, a paid lobbyist for Lee Memorial, said proposals for raising driving penalties for trauma care are modeled after Texas legislation.

"It will generate $30 to $40 million," he said. "It won't solve the funding problem but will help."

Saunders said he will support the measure but doesn't see it as the best long-term solution for the financial woes of trauma centers.

"There comes a point in time where you reach a point of diminishing return," he said, when driving violators won't be able to afford increasing fines and therefore just won't pay them — creating new problems for the legal system.

Saunders and state Rep. Carole Green, R-Fort Myers, are sponsoring bills that would protect physicians, nurses, dentists and other providers who care for the poor in charity-care clinics against malpractice claims. The providers cannot be reimbursed for the care they provide and the care has to be provided free of charge to the patients.

Saunders said what happens now is that a clinic will provide, for instance, radiation treatment for a child with cancer who is a charity patient but the clinic can get sued for malpractice if something goes awry.

"I consider that to be a pretty major issue. I've been able to get agreement on it from all the stakeholders," he said, referring to medical groups and the state trial attorneys' association.

The measure would benefit charity-care clinics run by the Salvation Army in Fort Myers and elsewhere.

"It's hard to get doctors to come in and treat the patients," Green said.

Another element of the bill is that it waives the license renewal fee each year for physicians who work in such clinics for free, similarly to physician volunteers who provide physical exams to student athletes every fall."That's $400 a year," said Nancy Lascheid, co-founder of the Neighborhood Health Clinic in Naples, which provides basic medical care to low-income working adults. "That would be very nice."

In a related malpractice matter, Green is sponsoring a bill that would provide radiologists with immunity from malpractice claims relating to mammograms only, except when the radiologist was grossly negligent.

At issue is how mammogram results aren't completely reliable, at no fault of the radiologist, but he or she gets sued by a woman down the road later diagnosed with breast cancer.

The consequence is fewer radiologists and radiation centers are willing to continue doing mammograms. The bill includes a 2006 sunset provision to evaulate the access issue.

"I am absolutely passionate about this issue," Green said. "We're looking to see that access to mammograms doesn't go away. There are anecdotal stories of fewer and fewer women are having access."

Another bill Green is sponsoring would enable nurse practitioners to prescribe pain medication under the supervision of a physician. Nurse practitioners have lobbied for years for such a measure, which always has garnered opposition from physician groups and is facing the same opposition now.

Green said a physician isn't always available in a hospice setting or nursing home to prescribe pain medication at the time when a patient needs it.

"We are one of five states that don't allow it," Green said. "People see nurse practitioners for their care. Why can't they write a 'script?"

Legislators will consider deregulating the cumbersome certificate-of-need (CON) process for hospital and other health-care projects. Deregulation has been considered for years but this year has a good chance of happening, given that the governor's office is at the helm of the movement with the backing of the Florida Hospital Association and regulatory agencies.

The plan is to move to a market demand system for hospitals seeking to add specialty services that now require a CON, such as for an open-heart unit for adults. A hospital would have to meet licensing guidelines to start the service and then meet good outcome standards to continue providing the service, said Rich Rasmussen, spokesman for the hospital association. Hospitals that don't meet good outcome standards could face corrective action by the state.

"There still would be the CON review for new hospitals and replacement hospitals," he said.

Saunders said a hospital wanting to do adult open-heart surgery or another specialty line would have to be providing a full array of health services, so the new licensing system avoids "boutique" hospitals springing up that only do one medical service that's profitable and would hurt community hospitals.

"I objected to a lot of the old (proposals) in the past because it didn't protect community hospitals," he said, adding that he thinks the chances are likely there will be CON deregulation this year.

The governor's office is likely to announce details of the proposals this week, Rasmussen said.

Another element of the deregulation may involve allowing hospitals to move existing beds to another location in the same community without having to go through the CON review. Currently, the bed transfer can be done only after approval through an expedited CON review.

"On the surface, it seems being able to move beds to where growth has gone seems logical to me," said Edward Morton, chief executive officer of the NCH Healthcare System.

NCH is in the planning stages now to move beds under the current rule from Naples Community Hospital near downtown Naples to North Collier Hospital off Immokalee Road.

Rasmussen, of the hospital association, said support for modernizing the regulations is even among investor-owned hospitals and non-profit hospitals. About 37 percent of the association's membership involves investor-owned hospitals.

"I think the support is pretty uniform across the state," he said. "In fact, our board of trustees are predominantly from not-for-profit hospitals."