Six Steps to a Health Plan’s Obligation with Opioids

There are many hot-button questions when it comes to the opioid epidemic in America, including a health plan’s obligation to address the issue. While opioids are typically prescribed to relieve pain associated with surgeries and chronic illness in an effort to enhance quality of life, sadly the addiction associated with this drug can have dire consequences.

Opioid addiction comes at a high cost. While more than two million Americans are addicted to opioids, the cost of caring for those with an opioid addiction is $78.5 billion. But those who pay the highest cost for opioid addiction are those who pay with their lives – more than 20,000 people a year, and rising.

Legally, and practically, healthcare compliance ensures organizations follow the laws and regulations put in place for the purpose of providing members with the services and care promised to them. And while compliance with existing rules is appropriate, there’s room to do more.

Here are six steps a health plan can implement to protect members from opioid addiction:

1. Educate. Consider starting an education program for providers, prescribers, and members to shine a light on the risks of opioid addiction and alternative methods of pain management.

2. Identify At-risk Populations. Individuals who receive opioid medication pre-surgery are more likely to result in longer hospital stays, which in turn can increase costs. Keeping this in mind, consider flagging members who are administered opioids pre-surgery for additional quality of care measures. Online opioid risk tools provide specific risk scores based on the patient and family history of drug, alcohol, and prescription abuse, psychological diseases, and history of sexual trauma. Additional studies have shown mental health or substance abuse disorders are additional risk factors.

3. Monitor Access. Consider developing lock-in programs in the clinical management area that limit where patients can go to a doctor or pharmacy, requiring additional authorization when a patient attempts to use alternate locations.

4. Understand Abuse. Review your data to identify providers associated with high prescribing rates of opioid drugs, seemingly using it as a “one-size-fits-all” approach. Make sure they are educated on alternative methods of pain relief management and remind them of your organization’s policy to maintain investigative oversight of medications prescribed – both to prevent patient abuse, as well as limit any opportunity for financial gain by the provider. Also, know what high-risk member behavior looks like – create flags for your case managers for doctor shopping, emergency room hopping, and other forms of addictive behavior.

5. Invest in Treatment Programs. Current estimates show that a year of treatment can cost $6,000 to $14,000 per member. The cost of emergency room services and complications from drug abuse are much higher. Review your policies and plans to make treatment programs accessible.

6. Share Resources. Coordinate with your vendors, pharmacy benefit managers, and therapeutic pharmaceutical agents as they are also working to get in front of the opioid crisis and help their members. Working together to manage the crisis now helps everyone involved.


Authors: Jean Lyon, HMS® Vice President Product Engineering; Ed Hewitt, HMS Payment Integrity Solutions Consultant; and Joannah Lewis, HMS FWA Senior Product Specialist. Read about HMS Fraud Solutions, or contact HMS for more information related to this blog.