Update on the Federal Response to the Opioid Crisis

DOJ Opioid Health Care Fraud Enforcement Efforts

The opioid crisis is catching everyone’s attention in the health care field these days. At the Health Care Compliance Association (HCCA) Compliance Institute last April, eleven of the presentations provided reactions to the opioid crisis, including a special focus expressed by the Department of Justice (DOJ). Additionally, the DOJ recently announced the largest ever health care fraud enforcement action involving 601 charged defendants across 58 federal districts. The defendants include 165 doctors, nurses, and other licensed medical professionals, that allegedly participated in opioid health care fraud schemes involving more than $2 billion in false billings. Of those charged, 162 defendants, including 76 doctors, were charged for their roles in prescribing and distributing opioids and other dangerous narcotics for unnecessary treatments, many of which were never provided. A good portion of these cases also violated the federal Anti-Kickback Statute (AKS). The fraud takedown resulted from a Medicare Strike Force led effort involving the Department of Health and Human Services (HHS) Office of Inspector General (OIG), Drug Enforcement Administration, Internal Revenue Service, and Medicaid Fraud Control Units, among other governmental agencies.

While this large enforcement action was taking place, Congress was moving on the issue as well. The U.S. House of Representatives (the House) overwhelmingly passed the “Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act” or the “SUPPORT for Patients and Communities Act” (H.R. 6) on June 22, 2018. This piece of legislation included about 60 proposals to combat the opioid crisis. The bill, endorsed by the White House, is now on the U.S. Senate Legislative Calendar.

The proposed House legislation includes a number of bills that aim to: increase access to addiction treatment; create a loan forgiveness program for addiction care providers in rural areas; encourage the use of non-opioid pain medicine after surgery; and, prevent opioid misuse in Medicare. The omnibus package also includes “Jessie’s Law”, which would make a patient’s addiction history a part of their medical records.

In recent congressional testimony, the OIG reported that prescription drug diversion is a serious component of this epidemic. Related health care fraud encompasses a broad range of criminal activity ranging from prescription drug diversion to addiction treatment schemes. The OIG reported the following:

• More than 50,000 Americans were reportedly dying from drug overdoses annually, and 63 percent of these cases involved opioids.
• Approximately three out of four new heroin users abused prescription opioids prior to using heroin.
• One in three (14.4 million) Medicare Part D beneficiaries received opioids.
• Approximately 500,000 beneficiaries received high amounts of opioids with nearly 70,000 beneficiaries receiving extreme amounts of opioids.
• The OIG identified 22,308 beneficiaries that appeared to be doctor shopping and received prescriptions from four or more prescribers and four or more pharmacies for opioids.

Compliance Experts to Help Your Organization

Our experts have over 40 years of experience assessing compliance program effectiveness. For a custom evaluation of your organization’s individual needs, give us a call at (703) 683-9600 or contact us online.