Third-Party Payer: Using Data to Limit Misuse and Abuse - Jo-Ellen Abou Nader and Phillip Walls

1. Third-­‐Party
Payer
Track:
Using
Data
to
Limit
Misuse
and
Abuse
Presenters:
Phillip
Walls,
RPh,
Chief
Clinical
and
Compliance
Officer,
myMatrixx
Jo-­‐Ellen
Abou
Nader,
CFE,
CIA,
CRMA,
Sr.
Director
of
Fraud,
Waste
&
Abuse
Services
Express
Scripts
Moderator:
Michelle
C.
Landers,
ExecuOve
Vice
President
&
General
Counsel,
Kentucky
Employers’
Mutual
Insurance

2. Disclosures:
• Phillip
Walls
has
disclosed
no
relevant,
real
or
apparent
personal
or
professional
financial
relaOonships.
• Jo-­‐Ellen
Abou
Nader
has
disclosed
no
relevant,
real
or
apparent
personal
or
professional
financial
relaOonships.

3. Learning
ObjecOves:
1. Define
how
prescripOon
drug
data
is
currently
being
used.
2. Demonstrate
an
understanding
of
strategies
for
mining
the
data
to
manage
drug
abuse.
3. IdenOfy
otherwise
easy
to
miss
cases
uOlizing
geomapping
and
recognizing
pa[erns
of
behavior.
4. Organize
collaboraOon
with
private
and
public
agencies
to
end
the
epidemic
of
prescripOon
drug
abuse.

4. Sources
of
Data
• PrescripOon
Drug
Monitoring
Programs
(PDMPs)
• Drug
Enforcement
AdministraOon
(DEA)
• NaOonal
Plan
and
Provider
EnumeraOon
System
(NPPES)
• Proprietary
Prescriber
Databases
• PharmaceuOcal
Manufacturers
• Pharmacy
Benefit
Managers
(PBMs)

5. Access
to
PDMPs
1. Law
Enforcement
2. Prescribers
3. Dispensing
Pharmacists
Denied
Access
to
PDMPs
1. Insurance
Companies
2. Clinical
Pharmacists
responsible
for
oversight
and
compliance

6. PDMP
16
States
Require
Mandatory
Use
of
PDMPs
for
Providers
(Includes
any
form
of
mandatory
use
requirements)
Colorado
Delaware
Kentucky
Louisiana
Massachuse[s
Minnesota
Nevada
New
Mexico
New
York
North
Carolina
Ohio
Oklahoma
Rhode
Island
Tennessee
Vermont
West
Virginia
34
States
and
DC
Do
Not
Require
Mandatory
Use
of
PDMPs
for
Providers
Alabama
Mississippi
Alaska
Missouri
Arizona
Montana
Arkansas
Nebraska
California
New
Hampshire
ConnecOcut
New
Jersey
D.C.
North
Dakota
Florida
Oregon
Georgia
Pennsylvania
Hawaii
South
Carolina
Idaho
South
Dakota
Illinois
Texas
Indiana
Utah
Iowa
Virginia
Kansas
Washington
Maine
Wisconsin
Maryland
Wyoming
Michigan

7. NABP
PMP
InterConnect:

8. Physician
Dispensing
and
PDMPs
Does
the
state
require
a
physician
to
report
to
the
state’s
PDMP
if
they
dispense?
#
of
States
Yes
26
Yes
in
specific
circumstances
3
No
20
N/A
(No
PDMP
or
no
Physician
Dispensing)
2
Total
51

9. DEA
1. AutomaOon
of
Reports
and
Consolidated
Orders
System
(ARCOS)
2. Controlled
Substances
Ordering
System
(CSOS)
3. Electronic
PrescripOons
for
Controlled
Substances
4. Criminal
Cases
Against
Doctors
5. AdministraOve
AcOons
Against
Doctors
6. DATA
Waived
Physicians
(Drug
Addiciton
and
Treatment
Act)
a. DEA
number
b. DATA
2000
waiver
ID
number
or
"X"
number

10. NaOonal
Plan
and
Provider
EnumeraOon
System
(NPPES)
• The
AdministraOve
SimplificaOon
provisions
of
the
Health
Insurance
Portability
and
Accountability
Act
of
1996
(HIPAA)
mandated
the
adopOon
of
standard
unique
idenOfiers
for
health
care
providers
and
health
plans
• The
Centers
for
Medicare
&
Medicaid
Services
(CMS)
has
developed
the
NaIonal
Plan
and
Provider
EnumeraIon
System
(NPPES)
to
assign
these
unique
idenOfiers.
• Unique
idenOfer
is
known
as
the
NaOonal
Provider
IdenOfier
(NPI)
• The
NPI
is
a
unique
idenOficaOon
number
for
covered
health
care
providers.
Covered
health
care
providers
and
all
health
plans
and
health
care
clearinghouses
must
use
the
NPIs
in
the
administraOve
and
financial
transacOons
adopted
under
HIPAA.
The
NPI
is
a
10-­‐posiOon,
intelligence-­‐free
numeric
idenOfier
(10-­‐digit
number).

11. Proprietary
Prescriber
Databases
1. NaOonal
Council
on
PrescripOon
Drug
Programs
(NCPDP)
HCIdea
a. Type
1
prescribers,
including
medical
doctors,
doctors
of
osteopathic
medicine,
naturopaths,
chiropractors,
denOsts,
nurse
pracOOoners,
physician
assistants,
optometrists,
podiatrists
and
other
allied
healthcare
professionals
who
are
authorized
to
prescribe
medicaOons,
supplies
or
medical
devices.
b. NPI
to
DEA
crosswalk
c. Surescripts
Provider
IdenOfier
(SPI)
ePrescribing
number
2. Health
Market
Science
a. Also
includes
state
medical
board
sancOons
b. OIG
sancOons

12. PharmaceuOcal
Manufacturers
OxyContin maker closely guards its
list of suspect doctors
Purdue Pharma has privately identified about 1,800 doctors
who may have recklessly prescribed the painkiller to addicts
and dealers, yet it has done little to alert authorities.
August 11, 2013|By Scott Glover and Lisa Girion
Over the last decade, the maker of the potent painkiller
OxyContin has compiled a database of hundreds of doctors
suspected of recklessly prescribing its pills to addicts and
drug dealers, but has done little to alert law enforcement or
medical authorities.
Despite its suspicions, Purdue Pharma continued to profit
from prescriptions written by these physicians, many of
whom were prolific prescribers of OxyContin. The company
has sold more than $27 billion worth of the drug since its
introduction in 1996.
Purdue has promoted the idea that the country's epidemic
of prescription drug deaths was fueled largely by pharmacy
robberies, doctor-shopping patients and teens raiding home
medicine cabinets. The database suggests that Purdue has
long known that physicians also play a significant role in the
crisis.
Purdue Pharma has sold more
than $27 billion worth of the
powerful painkiller… (Liz O.
Baylen, Los Angeles…)

13. PBMs

14. 1. U.S. Centers for Disease Control and Prevention. Feb 2012. http://www.cdc.gov/Features/VitalSigns/PainkillerOverdoses/
2. US. Substance Abuse and Mental Health Services Administration. Dec 2010. http://www.oas.samhsa.gov/2k10/DAWN034/
EDHighlights.htm
Each year,
prescription drug
overdoses KILL
more than
15,000
Americans1
and result in
1.2 MILLION
Emergency
Room Visits2

15. 1U.S. Centers for Disease Control and Prevention. Feb 2012. http://www.cdc.gov/Features/VitalSigns/PainkillerOverdoses/
2U.S. Substance Abuse and Mental Health Services Administration. Dec 2010. http://www.oas.samhsa.gov/2k10/DAWN034/EDHighlights.htm
This is a
NATIONAL
EPIDEMIC
with a
20%
expected annual
growth rate

16. $72.5 Billion in Annual Healthcare Costs

17. THE MEDICAL MULTIPLIER
2011
NaOonal
Survey
on
Drug
Use
and
Health
For every $1 of abused drugs obtained through “doctor shopping,”
an additional $41 are wasted on related medical claims

18. Sources for Nonmedical Users
Of Prescription Pain Meds
71%
Friend or
relative
18%
Rx direct from
MD
4%
Drug dealer
7%
Other
2011
NaOonal
Survey
on
Drug
Use
and
Health

19. Fraud Industry Trends
1
• Economic downturn causing increased client awareness for potential fraud
2
• Recent focus on health care reform = more media coverage
3
• Increase in drug abusers using prescription drugs in comparison to illegal drugs
4
• ID theft occurrence is more common
5
• “Off -label” prescribing of drugs to treat conditions beyond FDA-approved uses
6
• Newer drugs with greater potency have higher street value
7
• Organized crime contributes to increased prescription fraud

21. Defining the Problem: Fraud by Patients
64%
13%
11%
9%
3%
Drug-­‐seeking
Behavior
(AddicOon)
IdenOty
Thel
Forged
PrescripOons
DuplicaOve
/
Inappropriate
Therapy
Other
1%
21%
37%
28%
13%
65+
51-­‐64
35-­‐50
18-­‐34
<18
FRAUD TYPE PATIENT AGE

22. Type of Fraud
Pharmacy Locations
Defining the Problem: Fraud by Pharmacies

23. Workers’ Compensation Trends
Patient overutilization1
Overprescribing2
Prescribing outside of specialty3
Collusion4

24. EXAMPLE:
Drug-Seeking
Beneficiaries
Claims
Trending
Number
Physicians
and
Pharmacies
Number
Chains /
Independents
Number
Unique
GCNs
Number
Metropolitan
Service
Areas
High-Risk
Specialties
Short Days
of Supply
Number
Short-
Acting
Drugs
Fraud Analytics Scenarios
Types of Proactive
Patient Scenarios
Drug
Combos
HIV Meds
Cough
Syrups
Geographic
Concerns
High-Cost
Drugs
Duplicate
Therapy
Proactive. Multiple layers of criteria applied to full population.

25. Patient and Physician Investigation Methods
Full Claims Analysis
Physician Verifications
Patient Verifications
Pharmacy Outreach
Prescription Reviews
Medical Data Integration
Internet Research
Engage Law Enforcement
Gather and Review Evidence
Industry Leading Investigative Expertise
Generate Actionable Investigative Report

26. Case Study: Patient
Pharmacy lock-in limits drug-seeking activity
Patient obtained 43 controlled substance Rxs
from 17 prescribers and 5 pharmacies
59%
11%
6%
6%
6%
6%
6% Physician Specialties
Emergency Medicine
Orthopedic Surgery
Spine and Pain
Endocrinology
Cardiology
Internal Medicine
Psychiatry
Restriction to 1 pharmacy and 1 prescriber

27. Case Study: Patient
Therapy now appropriately managed.
Patient receives all pain medications
from one physician & one pharmacy
Outcome of a Successful Intervention
• Prescriber and Pharmacy Lock-In implemented
• Case manager assigned by medical vendor
• Patient opted for Employee Assistance Program
• Patient entered rehabilitation center

28. Physician prescribed controlled substances
more often than average. Analytics
spot anomalies with physician’s
specialty.
Case Background
• Reviewed prescriptions from January 2010-March 2013
• Physician practicing Pain Management despite being
registered as General Practice and Vascular Surgery
• 80% controlled substance ratio vs. 60% average in Pain
Management; and 12% average in GP and Vascular Surgery
• 62% Schedule II ratio
Case Study: Physician
Prescribing Pattern Raises Red Flag

29. Physician owns in-house pharmacy with
high rate of controlled substance use. Medical
claims and billed Rx claims don’t align.
Characteristics of a Pill Mill
Only pills prescribed
Uses specific pharmacies
No physician exam given
Only cash payments
Security guards
Out-of-state license plates
Loitering in parking lot
Long lines outside
Case Study: Pill Mill

30. It may also look like this….

31. They may react like this…
“Stop sending me this! I do not have time
and cannot pay staff to stop working and
do your paperwork….”

32. Case Study: Collusion
Potential collusion identified between
pharmacy, physician and patient
ALLEGATION
Patient discovered on a
geographic query
Patient was receiving non-controls
in MA and controls in FL
No medicals claims for physician
visits
Physician referred to DEA and
patient referred to FBI
Controls
Non-Controls

33. Key Takeaways
This national epidemic claims 15,000 lives and is
growing by as much as $54 billion a year1
PBM’s have a key role in reducing and fighting
prescription fraud, waste & abuse2
Prescribing data provides rich, actionable
information for spotting fraud trends and outliers3
Together, we can make a difference4

34. Thank
you!