The Department of Health and Human Services (HHS) Office of Inspector General (OIG) issued its Semiannual Report to Congress (Report) for Spring 2018. In the Report, the OIG identified the opioid epidemic as its top priority. Opioid fraud encompasses a broad range of criminal activity from prescription drug diversion to addiction treatment schemes. Many of these schemes are elaborate and involve multiple co-conspirators and health care professionals. The schemes often involve kickbacks, medical identity theft, and money-laundering. Opioid-related fraud investigations can be complex and often involve the use of informants, undercover operations, and surveillance. To address the complexity of opioid fraud and diversion cases, the OIG enhanced its tools to increase the efficiency of its investigations. The OIG also uses advanced data analytics to track trends of fraudulent activity and discover fraudulent schemes.
OIG Opioid Fraud Enforcement Efforts
The OIG collaborates with multiple government entities and private stakeholders to improve its enforcement efforts to combat the opioid crisis. For example, it has entered into a partnership with the Department of Justice through their new “Opioid Fraud and Abuse Detection Unit” (Detection Unit). The Detection Unit focuses on prosecuting individuals that contribute to the opioid epidemic through opioid-related health care fraud. The Detection Unit has been established in 12 judicial districts. For these districts, the OIG assigned Special Agents to support the 12 OIG identified prosecutors on opioid-related cases. Further, the OIG also collaborates with other agencies, such as the Centers for Medicare & Medicaid Services, the Agency for Community Living, and the Drug Enforcement Administration regarding other opioid-related initiatives.
In the Semiannual Report, the OIG also provided examples of significant cases that it investigated during the reporting period. For example, in one recent case, a physician and a patient recruiter were convicted of charges for their involvement in an unlawful prescription drug operation. Patient recruiters were bringing “patients” to the clinic to obtain medically unnecessary prescriptions for controlled substances. The physician illegally distributed over 700,000 dosage units of Hydrocodone, more than 240,000 dosage units of Alprazolam, and more than 2 million milliliters of promethazine with codeine cough syrup. In the black market, this is worth more than $15 million. In another recent case in Kentucky, a pharmacist was convicted on 71 counts and excluded for 50 years from Medicare and Medicaid for illegally dispensing oxycodone, hydrocodone, and pseudoephedrine. The physician was selling prescription pain medication without a legitimate medical purpose and pseudoephedrine, while knowing or having reason to believe that it was being used to manufacture methamphetamine. He was sentenced to 30 years in prison.
Additionally, in the OIG’s recent testimony before the U.S. Senate Special Committee on Aging, the OIG Deputy Inspector General for Investigations, Gary Cantrell, testified about statistics related to the consequence of opioid misuse. His testimony included the following information:
- In 2016 alone, more than 60,000 Americans died from drug overdoses;
- From those 60,000 that died from drug overdoses, two-thirds involved opioids;
- The Centers for Disease Control and Prevention reported that 75 percent of new heroin users abused prescription opioids prior to using heroin;
- One in three Medicare Part D beneficiaries, totaling 14.4 million beneficiaries, received opioid prescription in 2016;
- Approximately 500,000 beneficiaries received high amounts of opioids, excluding beneficiaries with a cancer diagnosis and those enrolled in hospice;
- Of the 500,000 beneficiaries that received high amounts of opioids, nearly 90,000 were at serious risk of opioid misuse or overdose;
- From the 90,000 at serious risk of opioid misuse or overdose, 69,563 beneficiaries received extreme amounts of opioids and 22,308 beneficiaries appeared to be doctor shopping; and
- From approximately 115,000 prescribers that ordered opioids for at least one beneficiary at serious risk of opioid misuse or overdose, about 400 prescribers exhibited questionable opioid prescribing patterns for beneficiaries at serious risk, resulting in 265,260 opioid prescriptions and costing Medicare Part D a total of $66.5 million.
Compliance Experts to Help Your Organization
Strategic Management Services has experts with over 40 years of experience evaluating and assessing compliance program effectiveness. If you would like to speak to one of our consultants about your organization’s individual needs, give us a call at (703) 683-9600 or contact us online.Subscribe to blog