Physician's Combating Medicare Drug Fraud

Not all cases where patients are receiving prescriptions for frequently abused drugs are fraudulent, but experts believe that many of them are. A recent Government Accountability Office report indicates that “170,000 Medicare beneficiaries received prescriptions from five or more” physicians for frequently abused drugs like OxyContin and Percocet.

“The problem with Medicare is that it doesn’t have controls set up on the front end,” says Linda Webb, president of Contego Services Group, and a long-standing expert in uncovering fraud. “We have to be more proactive. Everyone has to move faster.”

And physicians can do their part.

A challenging task

Webb says the challenge to bottling up Medicare drug fraud is that the people committing fraud are not dumb. They understand how the system works, and will bill just under the threshold that is designed to send up a red flag. And even if that threshold of X-amount of dollars billed per month is crossed, it’s only after tens of thousands of dollars in fraudulent claims have been processed and approved.

“Years ago when I worked as a burglary detective I told people that the problem with burglars is they’re going to commit five burglaries before you catch them,” Webb explains. “The same is true with the person committing fraud. Millions of dollars go out the door before you know who he or she is.”

Matt Haddad is the president and chief executive officer of Medversant Technologies, a leading health care information technology company. He says that with physicians seeing more and more patients on a daily basis, it’s easy to fall into a routine of simply refilling prescription based on patient phone calls.

“That’s where provider groups can get into trouble,” Haddad says. “If you’re a large or even mid-sized medical group, how are you monitoring the services that are going on within that group? It’s really important to take steps to examine how all your providers are prescribing.”

Webb echoes Haddad’s thoughts about issuing prescription refills via phone calls — especially where pain medication is concerned.

“I would never allow someone to just call in for a refill,” she says. “Make the patient come in and go through the ritual of explaining why they need the drug. Because chances are, if it’s someone selling on the street, they don’t want to go through that routine all the time.”

Know your patient

Webb suggests that the most important thing physicians can do is make certain they understand who their patients are. That includes asking for identification beyond a Medicare card, such as a driver’s license. Taking a thorough medical history is also important.

“Physicians also need to monitor what they’re dispensing, and not just give patients a blank form,” Webb says. “If a patient is on a fixed Social Security income of around $1,200 a month, and they can get a doctor to give them 100 OxyContin, which sell for $40 a pill on the street, they can sell it to a runner and get $20 a pill, or $2,000. Can you blame the patient for trying to enhance their income?”

Webb also suggests handing out information sheets to patients on how to report Medicare fraud.

“There’s a reward program offering up to $1,000,” Webb says. “Talk to your patients about the program, and show them that you’re serious about fighting Medicare fraud. Show them that you care.”

Haddad believes the use of electronic medical records and e-prescribing can help. With an EMR physicians can run an analysis of their patient population. Not unlike identifying which patients haven’t had a mammogram recently, physicians can proactively identify patients who have received refills but have not been in for a check-up.

“[Working with an electronic medical record] definitely affords the physician better oversight,” says Haddad.

Know your employees

According to Webb, when it comes to policing Medicare drug fraud, it’s also important for physicians to know whom they’re hiring. She explains that organized crime rings will put people called ‘goats’ inside a physician’s office. And just as traditional goats will eat through a field of grass a little at a time, these ‘goats’ inside a physician’s office will steal data a little at a time without anyone noticing.

“If an organized crime ring can put one person in every doctor’s office and siphon 10 patient numbers every day, that’s scary,” Webb says. “The person placed in the office might make minimum wage, but if they steal 10 patient names and get $50 per name, they make more money working for the organized crime ring. So, it’s important for doctors to understand whom they’re hiring.”

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