Doctor shopping cost four states $33 million in Medicaid fraud

Fresh off a House Subcommittee hearing in which legislators grilled the Centers for Medicare & Medicaid Services (CMS) regarding Part D fraud controls, the Government Accountability Office (GAO) released a report this week noting that four state Medicaid programs spent $33 million in 2011 on prescription drugs tied to doctor shopping.

In four states--Arizona, Florida, Michigan and New Jersey--16,000 beneficiaries visited five or more doctors in order to obtain prescriptions for antipsychotic or respiratory medication, according to the report. Additionally, 700 beneficiaries received a one-year supply of the same drug, an indication that they may have participated in drug-diversion schemes.

Specifically, the GAO found questionable Medicaid billing patterns that could indicate potential fraud, including beneficiaries who were prescribed high amounts of the same drug, beneficiaries who received specific drugs despite no other outpatient claims that would indicate the need for those drugs, and pharmacies that showed high numbers of brand-name drugs or submitted claims without a single adjustment to the claims transaction.

Federal law requires states to employ a Medicaid Drug Utilization Review program, which CMS oversees. Currently, states use a two-phase review process, starting with eligibility screening to prevent abuse before drugs are dispensed. The second phase consists of reviewing claims data to root out patterns of "fraud, abuse, gross overuse or medically unnecessary care," according to the GAO.

However, the GAO listed two additional measures, usually reserved for controlling narcotics, that states could take to detect fraud, including lock-in programs for non-controlled substances that limit beneficiary prescriptions of certain drugs to one doctor or pharmacy, and prohibiting automatic refills for certain prescriptions.

Ultimately, the watchdog agency recommended that CMS require states to report specific drug utilization review controls in order to improve oversight of the programs. CMS agreed with the recommendation.  

On the same day, CVS agreed to pay $450,000 to settle claims that several of its Rhode Island pharmacies forged opioid prescriptions that allegedly contributed to a drug diversion scheme. The CVS locations filled prescriptions written by a psychiatric nurse practitioner without the authority to prescribe controlled substances, according to the Rhode Island U.S. Attorney's Office.

Other states have been singled out for failing to control prescription drug fraud involving opioids. Last year, Missouri earned the label of "America's Drug Store" because it refused to implement a prescription drug monitoring program (PDMP). Meanwhile, the government has previously recommended all payers increase the use of PDMPs in an effort to prevent fraud, particularly when it comes to doctor shopping.

For more:
- read the GAO report
- here's the Rhode Island U.S. Attorney's announcement

Related Articles:
Electronic databases can help fight prescription painkiller abuse
How Missouri became 'America's drug store'
Sharpening the tool of prescription drug monitoring programs
'Doctor shopping' cases overwhelming state authorities
Doctor shopping: What to look for, how to prevent it

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