Publications & Presentations
June 1, 2016
From FierceHealthPayer: Antifraud

by Evan Sweeney

In the midst of the opioid addiction crisis, fraud investigators and state and federal prosecutors are conducting more targeted investigations to uncover doctor-shopping schemes that can rack up millions in unnecessary medical costs and prescription drug reimbursements, sources tell FierceHealthPayer: AntiFraud in exclusive interviews.

Spending on commonly abused opioids within Medicare Part D has increased 156 percent between 2006 and 2014, according to an Office of Inspector General report. During the same period, overall spending within the program grew 136 percent, while beneficiary enrollment grew 68 percent. Perhaps even more telling, the average number of prescriptions for commonly abused opioids per beneficiary increased 20 percent, compared to 3 percent for all drugs.

Meanwhile, opioid addiction has given rise to fraud schemes, including drug diversion and doctor-shopping. In some cases, providers are complicit in the schemes, accepting cash payment for opioid prescriptions. In other instances, unsuspecting providers write prescriptions to addicts who have visited dozens of doctors over the course of a month.

These schemes--whether perpetrated by the provider or the patient--are difficult for law enforcement officials to break up, according to Bill Killian, an attorney with Polsinelli in Chattanooga, Tennessee, and the former U.S. Attorney for the Eastern District of Tennessee.

"The biggest problem from a law enforcement standpoint is there is a legitimate path to getting those prescriptions versus cocaine or heroin on the street," Killian said in an exclusive interview with FierceHealthPayer: Antifraud. "Opioid prescriptions have a legitimate source where there is a doctor that writes the prescription and it gets filled by a pharmacy."

These schemes have created a ripple effect throughout the healthcare industry in which the improper payments tied to prescription drugs often pale in comparison to the unnecessary medical costs that accompany elaborate doctor-shopping schemes. Drug diversion coupled with over prescribing has also spurred the growth in heroin addiction, a cheaper alternative to prescription painkillers.