Stemming Narcotics Fraud

Jay Krueger


March 1, 2012

Open the paper and you're likely to see an article on prescription drug abuse. On one hand, we're fortunate to live in a time when pain medications exist. On the other, the fact that these narcotics are so addictive presents society with a great challenge. As many workplace injuries involve chronic pain, the misuse of these drugs is a problem that threatens the health and lives of injured workers, prevents return-to-work and adds to workers comp claims costs. But there are some steps companies can take to limit their exposure to this risk.

Ultimately, the challenge for the workers compensation industry is to facilitate the appropriate use of pain pills while preventing the misuse and waste of costly drugs. The goal is to help employees control their pain in a way that hastens their return to work and improves their quality of life. Preventing fraud and abuse helps everyone reach it.

In one actual workers comp claim case, an injured worker was prescribed four legitimate medications, a number not unusual for workers compensation cases. Because of these multiple prescriptions, however, the workers compensation pharmacy benefit management (PBM) firm identified him as a candidate for urine drug testing. The physician concurred, and a random urine test was ordered.

The testing found only two of the four prescription drugs present, while a fifth drug that had not been prescribed was detected. A review of the medication profile showed that the patient had been consistently filling the medications not present in the urine, thus suggesting compliance or diversion issues. Additionally, there were no prescriptions for the fifth drug.

Because of these inconsistent results, the injured worker was enrolled in a drug-testing and monitoring program. A few weeks later, however, further testing showed that the injured worker still was not complying with the prescribed therapy. Because there were narcotics present that should not have been there as well as the absence of prescribed narcotics, the prescriber chose to dismiss this individual from the clinical practice for violating the agreed-upon narcotic treatment plan. The PBM then informed the payer of the prescriber's decision to prevent the injured worker from finding an unsuspecting prescriber to continue the pattern of misuse.

This case is not unique. According to the latest annual drug trend report from workers comp service provider PMSI, 70% of total pharmacy spending in workers compensation is related to medications used to treat pain. And narcotic pain medications as a group accounted for 34% of overall drug costs. Claims involving schedule II opioids (such as Percocet and Oxycontin) incur an added cost of $20,000 per claim and a delay in return to work that is six times longer than the norm.

Financial losses are only part of the negative implications of fraud and abuse. The clinical dangers are just as alarming. They include adverse drug reactions and drug therapy complications, cumulative side effects (such as sedation that impairs the patient's functional status and hampers the likelihood of return to work), and inappropriate dosing, which can lead to serious and sometimes fatal consequences.

How prevalent is the misuse and fraudulent use of narcotic drugs in workers compensation cases? PMSI detects the presence of two or more opioid prescribers (an indication of misuse) in almost 2.5% of the injured worker population suffering from chronic pain.

Another indication of the existence of misuse is the higher volumes of narcotic medications used in certain jurisdictions. Workers in Louisiana, Pennsylvania, Massachusetts and New York received significantly more narcotics per claim than in other states -- up to 125% more -- according to a report from the Workers Compensation Research Institute.

The study also found that only 7% of long-term narcotics users were screened for drugs, despite the fact that medical guidelines recommend periodic urine tests for drug screening for patients who are long-term users of narcotics. In the absence of this oversight, fraud is easier to perpetrate.

Clinical Pain Management
Clinical pain management programs deter narcotics fraud and abuse while helping to lower costs and improve patient outcomes. If you elect to use one, there are a four elements of a pain management program that risk managers should understand.

The first is a group of tools referred to as utilization control strategies. These are techniques that help manage access to drugs by weighing criteria to evaluate how appropriate and cost effective medication is. By scrutinizing the list of drugs that may be prescribed, ensuring that there is prior authorization for prescriptions, and converting patients to generic drugs when possible, there can be significant savings. Just by managing the list of drugs available to be prescribed, companies have seen an average savings of 28% in prescription drug costs per high-risk injured worker.

The second element is a targeted intervention program. Through this, administrators use analytics to cut down on the inappropriate use, duplication and potential abuse of medication. Methods include profiling high-risk patients and converting claimants from multiple prescribers to a single prescriber. Targeted intervention has shown a 90% success rate in eliminating multiple narcotic prescribers.

Next comes care management, which aims to improve medication-related outcomes for chronically injured, high-risk patients. One tool used is a medication review, in which a clinical pharmacist who specializes in pain management for occupational injuries assesses the patient's drug therapy and develops a plan for pain management. That may sound basic, but it often goes undone. Through this process alone, administrators have had a 64% success rate in eliminating inappropriate medication therapies.

Last—but perhaps most important—comes education. These programs can be vital for helping patients, prescribers and claims professionals understand the appropriate use of opioids. If all the parties involved become better versed in the true goals of pain control, it will greatly reduce the likelihood of opioid abuse and misappropriation.
Jay Krueger is chief strategy officer for PMSI, a provider of specialty workers compensation products and services.