According to the National Institutes of Health (NIH) nearly a quarter of the 2.1 billion prescriptions written a year were used for something other than a medical reason.  Although teenagers make up the largest percentage of drug abusers, everyone is susceptible to prescription abuse.   This inappropriate use of prescription drugs is called drug diversion and costs insurers over $72 billion a year.

Of the 2.1 billion prescriptions the American Medical Association estimates are written annually, nearly 25 percent of those were used by approximately 52 million Americans for something other than a medical reason. So says the National Institutes of Health (NIH). While teenagers make up a large percentage of drug abusers, nearly every age group is susceptible to prescription abuse.

One would think with preventable costs that high, insurers should be on top of the problem. Yet they aren’t, according to James Quiggle, Coalition Against Fraud’s director of communications. With billions of prescription drug claims to process annually, claims departments often lack the time or additional resources needed to fully investigate potential fraud. He said his organization’s report shows that while some health insurers are actively involved in identifying fraud and abuse, many don’t realize there’s a problem.

Insurance companies’ claims adjusters and departments are the ones who can help curb this drug diversion. Data mining software can be effective in identifying fraud, according to the Insurance Information Institute. Patterns in prescription fulfillment, frequency of prescriptions and “doctor shopping,” in which patients go to different doctors to obtain the same prescriptions repeatedly, can be pulled automatically from records. Claims staff can then determine the severity, prioritize and send the data to investigators.

Linda Webb, president of Contego Services Group, career fraud investigative expert, and star of the upcoming pilot production “Fraud Dog,” said the industry needs to rethink the claims process. Putting investigative measures and prevention at the front-end of a claim filing can save untold amounts of money for companies and insurers, she said.

“Webb suggested claims departments have a strong medical team, as well as pain management teams monitoring prescription drug use. Understand the claimant and the viability of the claim, Webb advised. “Was the claimant actually injured? Have there been multiple prior claims? How many prior hospital visits and [how much] pharmacy use is there?”

Webb recommends monitoring at the beginning of the claim for thwarting a problem before it begins. “For claims companies that are very aggressive in their investigations, they will see those patterns, and they should be questioning that,” she said.  If they or their family members have had multiple claims, that’s also a red flag, Webb added. “We’re in multi-generational fraud cycles,” she said. “It’s been passed down. It becomes a learned behavior.”

According to the NIH there are three categories of drugs most abused — opioids (pain relievers), central nervous system depressants (anxiety/sleep disorder treatments), and stimulants (for conditions such as ADHD and narcolepsy). The opioids are most-abused drugs accounting for 210 million prescriptions annually.

Webb agrees that the sharing of information among pharmacies has been a huge improvement in the past decade. She recommends all players in the management cycle — insurers, doctors, claims personnel, pharmacies, pain management companies and nurse case management — conduct due diligence to help prevent this fraud.

If you are in need of fraud investigation services, contact Contego Services Group today. Under the leadership of Linda Webb, The Fraud Dog, Contego has the knowledge and expertise to help you resolve your fraud case. Whether it’s mortgage fraud, insurance fraud, workers compensation fraud or any other type of fraudulent activity, Contego and The Fraud Dog will work together to help you and your company. For more information, call 1-855-WE-SWARM today.

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