WellPoint is taking a tough stance to try to combat prescription drug abuse and fraud activities that bubble to the surface through predictive analytics and other data runs of its members and their providers and pharmacies.
Illegitimate use of prescription drugs, especially of opiates, is a complex and deadly problem in healthcare, and expensive for insurers that pay the claims through their health plans and Part D Medicare prescription drug plans.
"It's not the drugs that are costing us – it's the facilities' fees that accompany them," said Alanna Lavelle, director of enterprise investigations at WellPoint and a former FBI agent, at a recent conference sponsored by America's Health Insurance Plans (AHIP).
For every $1 the payer spent on an opiate, it spent $40 for the facility fee, typically the emergency room visit for the member to get the script.
"On top of that we are seeing that a lot of our members use soft tissue complaints to get their prescription drugs because they are not verifiable types of illness, such as migraine, spinal pain, tooth ache, and a lot of them are getting unnecessary CT scans," she said.
WellPoint has intervened with members in crisis or at risk for harmful use through case management. It also tracks provider practices to try to find those over prescribing the medications.
"There are the fringe doctors who set up pill mills and pain management centers so that they can churn patients knowing that they'll be in every 30 days for their scripts and they add on additional procedures," she said, noting that some of them make up to $1 million a year just from WellPoint.
New schemes are constantly emerging around overutilization and fraudulent prescribing, with a many coming out of Dade County, FL, and up the East Coast. "Because of our size, we can track claims coming from southern Florida to northern Maine to California. And we can use our geo and analytics to drill down on some of the trends," Lavelle said.
Doctor-shopping, where an individual goes from doctor to doctor to get scripts, is a growing trend, thinking that they are staying under the radar and will not be detected. One Part D member visited 58 different prescribers in one year, 29 of them at different ERs. "That's almost a full time job to keep up their habit. What we're seeing is that they are diverting half of them to make an income and ingesting the rest," she said.
Criminal enterprises and individuals also are defrauding the healthcare system. Groups coming out of Florida; Glendale, Calif.; and Houston, Tex., are involved in the prescription drug trade.
WellPoint has a number of programs and tactics to combat this fraud and abuse, including:
• Controlled substance utilization monitoring program to prevent members who have a pattern of obtaining multiple prescriptions for controlled substances and use multiple pharmacies over a three-month period from continuing to do so by alerting them to oversight of their drug activity and tightly managing their case
• Medicaid restricted recipient program, implemented in Indiana and Virginia, which restricts members who have been identified as unable to be case managed to just one prescribing physician and one pharmacy for their opioids and one ER for non-emergency problems, but may use other providers and pharmacies for other medications.
• Operation Pillbox, in which WellPoint's investigative unit with its California plan identifies providers who are prescribing these addictive drugs with no medical justification and referring many to law enforcement with subsequent indictments this year. One physician was linked to the overdose deaths of 13 of his patients.
• Pre-pay provider review program for those whose practice pattern veer dramatically from the norm and drive cost spikes in certain counties because of incorrect coding or overprescribing. The claim is reviewed against medical records before payment is made.
• Bogus providers, pharmacies and identity theft, in which criminals purchase or steal National Provider Identification numbers and patient ID numbers and establish a fake storefront or post office box and then bill insurers for fraudulent services, prescriptions and devices. In California, WellPoint has stopped 300 bogus durable medical equipment companies before they could submit fraudulent claims to the company and targeted 70 bogus pharmacies this year through collaboration with its pharmacy benefits manager Express Scripts, thereby stopping $2.1 million in payments.