Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Third-­‐Party	
  Payer	
  Track:	
  
Using	
  Data	
  to	
  Limit	
  Misuse	
  and	
  Abuse	
  
Presenters:	
  	
  
Philli...
Disclosures:	
  
•  Phillip	
  Walls	
  has	
  disclosed	
  no	
  relevant,	
  real	
  or	
  apparent	
  personal	
  or	
 ...
Learning	
  ObjecOves:	
  
1.  Define	
  how	
  prescripOon	
  drug	
  data	
  is	
  currently	
  being	
  used.	
  	
  	
 ...
Sources	
  of	
  Data	
  
•  PrescripOon	
  Drug	
  Monitoring	
  Programs	
  (PDMPs)	
  
•  Drug	
  Enforcement	
  Admini...
Access	
  to	
  PDMPs	
  
1.  Law	
  Enforcement	
  
2.  Prescribers	
  
3.  Dispensing	
  Pharmacists	
  
Denied	
  Acces...
PDMP	
  
16	
  States	
  Require	
  Mandatory	
  Use	
  of	
  PDMPs	
  for	
  Providers	
  	
  
(Includes	
  any	
  form	
...
NABP	
  PMP	
  InterConnect:	
  
Physician	
  Dispensing	
  and	
  PDMPs	
  
Does	
  the	
  state	
  require	
  a	
  physician	
  to	
  report	
  to	
  the...
DEA	
  
1.  AutomaOon	
  of	
  Reports	
  and	
  Consolidated	
  Orders	
  System	
  (ARCOS)	
  
2.  Controlled	
  Substan...
NaOonal	
  Plan	
  and	
  Provider	
  EnumeraOon	
  
System	
  (NPPES)	
  
• The	
  AdministraOve	
  SimplificaOon	
  provi...
Proprietary	
  Prescriber	
  Databases	
  
1.  NaOonal	
  Council	
  on	
  PrescripOon	
  Drug	
  Programs	
  (NCPDP)	
  H...
PharmaceuOcal	
  Manufacturers	
  
OxyContin maker closely guards its
list of suspect doctors
Purdue Pharma has privately ...
PBMs	
  
1. U.S. Centers for Disease Control and Prevention. Feb 2012. http://www.cdc.gov/Features/VitalSigns/PainkillerOverdoses/
...
1U.S. Centers for Disease Control and Prevention. Feb 2012. http://www.cdc.gov/Features/VitalSigns/PainkillerOverdoses/
2U...
$72.5 Billion in Annual Healthcare Costs
THE MEDICAL MULTIPLIER
2011	
  NaOonal	
  Survey	
  on	
  Drug	
  Use	
  and	
  Health	
  
For every $1 of abused drugs ob...
Sources for Nonmedical Users
Of Prescription Pain Meds
71%
Friend or
relative
18%
Rx direct from
MD
4%
Drug dealer
7%
Othe...
Fraud Industry Trends
1
• Economic downturn causing increased client awareness for potential fraud
2
• Recent focus on hea...
Defining the Problem: Fraud by Patients
64%	
  
13%	
  
11%	
  
9%	
  
3%	
  
Drug-­‐seeking	
  
Behavior	
  
(AddicOon)	
...
Type of Fraud
Pharmacy Locations
Defining the Problem: Fraud by Pharmacies
Workers’ Compensation Trends
Patient overutilization1
Overprescribing2
Prescribing outside of specialty3
Collusion4
EXAMPLE:
Drug-Seeking
Beneficiaries
Claims
Trending
Number
Physicians
and
Pharmacies
Number
Chains /
Independents
Number
U...
Patient and Physician Investigation Methods
Full Claims Analysis
Physician Verifications
Patient Verifications
Pharmacy Ou...
Case Study: Patient
Pharmacy lock-in limits drug-seeking activity
Patient obtained 43 controlled substance Rxs
from 17 pre...
Case Study: Patient
Therapy now appropriately managed.
Patient receives all pain medications
from one physician & one phar...
Physician prescribed controlled substances
more often than average. Analytics
spot anomalies with physician’s
specialty.
C...
Physician owns in-house pharmacy with
high rate of controlled substance use. Medical
claims and billed Rx claims don’t ali...
It may also look like this….
They may react like this…
“Stop sending me this! I do not have time
and cannot pay staff to stop working and
do your paper...
Case Study: Collusion
Potential collusion identified between
pharmacy, physician and patient
ALLEGATION	
  
Patient discov...
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...
Thank	
  you!	
  
Tpp 1 walls abou_nader
Upcoming SlideShare
Loading in …5
×

Tpp 1 walls abou_nader

846 views

Published on

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

  • Be the first to comment

Tpp 1 walls abou_nader

  1. 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. 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. 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. 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. 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. 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. 7. NABP  PMP  InterConnect:  
  8. 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. 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. 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. 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. 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. 13. PBMs  
  14. 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. 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. 16. $72.5 Billion in Annual Healthcare Costs
  17. 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. 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. 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
  20. 20. 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
  21. 21. Type of Fraud Pharmacy Locations Defining the Problem: Fraud by Pharmacies
  22. 22. Workers’ Compensation Trends Patient overutilization1 Overprescribing2 Prescribing outside of specialty3 Collusion4
  23. 23. 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.
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. It may also look like this….
  30. 30. 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….”
  31. 31. 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
  32. 32. 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
  33. 33. Thank  you!  

×