The Opioid Crisis: When Healthcare Fraud Turns Deadly

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Last month, President Trump declared the Opioid crisis a public health emergency. And, with good reason: an average of more than 140 people die of Opioid overdoses each day. When Medicaid is defrauded by providers through “pill mills” or patients via “doctor shopping” for Opioids, taxpayers bear the burden of the financial and human cost – all too often, death.

One reason the Opioid problem poses such a challenge for public health agencies is that those combating the issues are usually confined to analyze data about patients or providers within their network. What’s needed is access to external data and analytics for a clear picture of who is involved in prescribing the Opioids (the provider), who is taking the Opioids (the patient) and who is dispensing the Opioids (the pharmacist) and instances of non-obvious relationships between all parties.

  • Providers – By overlaying outside provider data on medical claims, a Medicaid program could have a better understanding of the professional credentials of an opioid prescriber of (Is the doctor sanctioned? Has he/she had a license revoked in another state?). Similarly, the Medicaid program could look for personal motivators to conduct illegal activity. For example, is the doctor in financial distress? Are there leans or judgments issued against him/her?
  • Patients – Patients can illegally obtain opioids in a number of ways, namely: doctor shopping and identity-based fraud. By reviewing a patient’s medical claims data, the Medicaid program can determine whether a patient is getting the Opioid prescription filled by multiple physicians – a sign of doctor shopping. Having an accurate identity resolution process in place can minimize this abuse. Criminals use stolen identities or the identities of the deceased to steal and then sell Opioids. To detect these types of fraud, a Medicaid program must leverage public records data for identity risk analysis and verification.
  • Pharmacists – Pharmacists dispense prescription medication to the sick. And, they do a good job of it. According to Gallup’s 2016 poll of the most trusted professions, pharmacists rank second behind nurses and ahead of medical doctors. Pharmacists must have effective controls in place to guard against patients who present prescriptions generated through doctor shopping or stolen identities.

When a Medicaid program has access to outside data, such as medical claims, pharmacy claims, provider and public records data they can begin to triangulate and detect fraud Opioid fraud rings.

Finding Opioid fraud may seem daunting. To shut it down completely requires law enforcement. In August Attorney General Sessions announced an Opioid Fraud and Abuse Detection Unit. This unit will use data and analytics to prosecute criminals contributing to the Opioid Crisis.

The Opioid Crisis is now a Public Health Emergency. Combating the crisis and the criminals using fraud to perpetrate it (and often using taxpayer-funded dollars to do so), is critical. It is going to take data from multiple sources – providers, medical claims, pharmacy claims, public records, law enforcement records management system, computer-aided dispatch and more – to win. Siloed data will be the enemy of success, but data sharing will enable success.

Justin Hyde is Director, Market Planning, Health and Human Services, LexisNexis Risk Solutions. Justin is spearheading the company’s efforts to help innovative state healthcare programs to combat the opioid epidemic. He is also a frequent speaker on the topic of using data and analytics to improve HHS programs.

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Justin Hyde, Director of Market Planning, Health and Human Services, LexisNexis Risk Solutions
Justin Hyde is Director, Market Planning, Health and Human Services State and Local Programs, for LexisNexis Risk Solutions. He is a key member of the organization’s Government Sector, working closely with Health and Human Services agencies nationwide. Mr. Hyde oversees the strategic direction of identity solutions that are focused on preventing, detecting, and deterring fraud, waste, and abuse in Medicaid and other programs. He also directs the design and deployment of these technologies and manages a team of solution architects. Mr. Hyde is an experienced program manager who directed the implementation of the Florida Department of Children and Families Customer Authentication project as part of their integrated eligibility system. He has also managed numerous successful implementations across various State and Federal HHS programs. He is an Active Certified Fraud Examiner (CFE) and has also earned Project Management Professional(PMP) certifications.