The Painful Side Effects of Opioid Fraud

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Fighting the phantom with proactive approaches to analytics, partnerships, and investigations

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Why Opioid Fraud Matters

Opioid fraud and abuse are escalating in both human and financial costs. The issue is of such importance that President Barack Obama included it in the National Drug Control Strategy and devoted a Saturday radio address to the topic.

The reasons for concern are clear:

  • The direct correlation between prescription-painkiller sales and drug-poisoning deaths

According to the Centers for Disease Control and Prevention, sales of prescription opioids have quadrupled since 1999 — and so have overdose deaths involving these prescription drugs. Three-quarters of prescription-drugoverdose deaths in 2011 involved a prescription-opioid pain reliever.

  • New hepatitis C virus (HCV) and human immunodeficiency virus (HIV) outbreaks

The increase in cases of HCV and HIV may be due in part to increased misuse of prescription opioids. In 2010, the Massachusetts Department of Public Health found most of the young people diagnosed with HCV were injection-drug users who began misusing oral oxycodone around 12 to 18 months before injecting heroin. Researchers studying data from the National Household Survey on Drug Abuse estimate that as many as 45% of 18- to 29-year-old injectors are infected with HCV.1 A similar trend is found in HIV diagnoses, as in Indiana, where high numbers of new diagnoses are occurring among young people injecting prescription opioids or heroin. Other states are braced for similar growth.

Curbing opioid fraud and abuse is a critical issue for healthcare providers and payers. As lives are lost, health outcomes compromised, and costs mount.

  • Increasing healthcare costs

Healthcare costs for opioid abusers are eight times higher than for nonabusers. A new retrospective cohort study shows a 72% increase in hospitalizations related to opioid abuse/dependence from 2002 to 2012. Not surprisingly, inpatient charges more than quadrupled over that time. In 2012 alone, the approximate total cost of an opioid-related hospitalization was more than $28,000, rising to $107,000 for patients with a related infection.2

Types of Opioid Fraud

  • Pill mills: Doctors, clinics, or pharmacists who inappropriately prescribe or dispense without proper paperwork or medical examination.
  • Script mills: Pharmacies that don’t require hard-copy prescriptions or, in some cases, any prescription to dispense.
  • Doctor shopping: People obtaining controlled substances from multiple practitioners who are unaware of other prescriptions.

Proactive Approaches to Address Opioid Fraud

This raft of data shows that the epidemic is serious, but it isn’t beyond control. Swift identification and intervention empower you to reduce the effect. There are three effective ways to identify and act on opioid fraud: analytics, partnerships, and investigations. Here’s a quick review of each:

  1. Analytics
    Algorithms and scenarios: Algorithms pinpoint individuals, pharmacies, and prescribers whose activities may indicate abuse or fraudulent dispensing. This enables predictive or retrospective analysis based on use criteria, such as multiple contraindicated drug prescriptions for a single patient, number of providers, or substance abuse claims.Nodes: Nodes provide a graphical display of associations between multiple patients, pharmacies, and doctors that may indicate script mills. These data visualizations speed comprehension of issues and provide valuable tools to help with investigations.Geospatial data: This data-visualization technique can identify hot spots where opioid prescriptions or claims are higher than average, which may indicate fraud and abuse.It also maps provider, pharmacy, and member addresses to indicate potential doctor shopping. These data show intent to defraud and are useful evidence if prosecution is pursued.
  2. Partnerships
    Fraud and abuse schemes take advantage of healthcare-system silos, so increased visibility and collaboration are important tools in the fight. Creating data repositories and opening lines of communication between pharmacies, medical review, providers, and benefits management make it easier to identify patterns by connecting the dots. It’s also the best way to improve patient care and outcomes and contain costs.
  3. Investigations
    Analytics and partnerships provide a wealth of useful information that — when added to chart notes, interviews, and claims histories — creates a comprehensive collection of patterns and incidents. It also speeds discovery, which is crucial because of look-back period caps and statutes of limitations. Investigations may begin as peer-to-peer or internal medical/claims review, and then involve law enforcement.


Curbing opioid fraud and abuse is a critical issue for healthcare providers and payers. As lives are lost, health outcomes compromised, and costs mount, we must respond quickly with proven interventions and processes.

Combined, the tactics outlined here can deliver outsized results in fighting fraud and helping those with addiction and abuse issues.

Evaluate your current costs and the potential savings of taking proactive steps to contain this problem. Doing so will have a positive effect on members’ lives and help you control spending and reduce liability.

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