Healthcare Fraud Shield’s Latest Article: Opioid Crisis in America and FWA

8 Apr
Opioid abuse and overdose deaths are at epidemic levels in the United States. Opioids, sometimes called narcotics, are a type of drug used to treat moderate to severe pain. They include strong prescription pain relievers, such as oxycodone, hydrocodone, fentanyl, and tramadol. The illegal drug heroin is also an opioid. Some opioids are made from the opium plant, and others are synthetic (man-made). Most opioids are classified as Schedule II controlled substances. Substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence.
Opioid fraud schemes and networks of pill mill clinics can not only be a multimillion-dollar business, but endangers lives and costs the healthcare system billions of dollars each year. By identifying and mitigating potentially fraudulent, abusive, or wasteful activities related to opioids, we play an important role in dismantling the epidemic.


What type of schemes should you look for?
  • Pharmacies filling prescriptions for highly abused prescription-drug cocktails especially for long-distance patients
  • A pharmacy excessively dispensing opioid prescriptions for multiple members of the same family
  • The pharmacy dispensing controlled-substance prescriptions for patients engage in doctor/pharmacy shopping
  • Pharmacy receiving dinners, cash, rebates and discounts from drug companies
  • Pharmacies hiring marketing firms to hire recruiters to find patients
  • Pharmacies offering physicians a percentage of insurance reimbursement to write scripts and send them to your pharmacy 
If suspicious behavior or predication exists, conduct audits and analysis of the following:
Prescriber Audits
  • Are Medication Management visits provided in line with Controlled Substance requirements
  • Writing excessive prescriptions for controlled substances
  • Claims with only one visit from several patients
  • High percentages of patients with diagnosis of chronic pain
  • Is this prescriber allowed to prescribe these medications?
  • Is the prescriber utilizing the Prescription Drug Monitoring Programs (PDMPs) to determine concurrent opioid use?
  • Is the prescriber performing urine drug test screening to test for concurrent illicit drug use?
 Pharmacy Audits
  • High dollar average claim amounts
  • Quantity dispensed versus the days supplied
  • Confirm the pharmacies dispensing is in line with FDA guidelines
  • Quantity dispensed versus prescription drug program limitations
  • Look for excessive claim reversals
  • Compounding (high claim amounts billed or average ingredient cost too high)
  • Excessive amounts of Controlled Substances being dispensed compared to peers
  • Invalid DEA, NPI, or state board license number in the incorrect NCPDP field
  • Submitting smaller package sizes for large quantities of medications
  • Dispensing prescriptions written by an excluded provider
  • Excessive early refill overrides
  • Counterfeit prescription pads 
Member Audits
  • Review claim history for member filling prescriptions at several different pharmacies
  • Review history for members seeing several different physicians
  • Review history for excessive Emergency Department visits
  • Diagnosis of chronic pain
  • Insurance denials paid by cash
  • Requests for early refills
  • Auto refills
  • Prescriptions filled 100 miles or more from residence, or located in a different state
  • Physician visits 100 miles or more from residence, or located in a different state
If you have any questions or comments, please contact
1) DEA
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