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Tpp 1 walls abou_nader
This document summarizes a presentation on using prescription drug data to limit misuse and abuse by third-party payers. The presentation features speakers from myMatrixx and Express Scripts discussing how data from sources like prescription drug monitoring programs, the DEA, NPPES, proprietary databases, and pharmaceutical manufacturers can be mined and analyzed to identify problematic prescribing patterns, problem geographic areas, and individual doctors who may be recklessly prescribing controlled substances. The goal is to organize collaboration between private and public agencies to help address the epidemic of prescription drug abuse.
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Tpp 1 walls abou_nader
- 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
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- 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 OxyContinmaker 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…)
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- 14. 1. U.S. Centersfor 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 forDisease 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 inAnnual 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 NonmedicalUsers 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 • Economicdownturn 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 PharmacyLocations Defining the Problem: Fraud by Pharmacies
- 23. Workers’ Compensation Trends Patientoverutilization1 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 ofSupply 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 PhysicianInvestigation 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 Pharmacylock-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 Therapynow 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 controlledsubstances 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-housepharmacy 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 alsolook like this….
- 31. They may reactlike 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 Potentialcollusion 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 nationalepidemic 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
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