Signs of prescription medication fraud and how to stop it

Published April 26, 2017

On April 29, thousands of police stations and law enforcement offices across the country will open their doors to people looking to dispose of prescription medications. It’s National Drug Take Back Day, an event organized twice a year by the Drug Enforcement Administration (DEA) to remove unneeded – and potentially dangerous – medications from homes and communities.

Prescription medication abuse is one of the greatest public health crises facing our nation today, tearing apart families, devastating communities and driving up medical costs. There’s often an untold side of the story – prescription medication fraud – which enables people to get access to prescription medicines without medical justification, resulting in billions of dollars in wasted medical costs and millions of lives endangered.

What is prescription medication fraud?

Prescription fraud happens when people obtain medications by deception. Some may use forged prescriptions. Others obtain prescriptions from medical facilities that are willing to engage in unethical practices. Some people visit doctor after doctor until they find one willing to prescribe. This fraud and abuse comes at an enormous cost to physicians, hospitals, insurers and taxpayers. But the greatest cost is a human one – the tens of thousands of lives lost to addiction, and the relatives and friends they leave behind. According to the Centers for Disease Control and Prevention, about 15,000 people die each year from prescription medicine overdoses. And overdoses lead to an additional 1.2 million emergency room visits each year.

Prescription drug fraud by region: At 48%, the south contains the majority of prescription drug fraud found in the United States. The East accounts for 26%, the West for 20%, and 6% in the Central region.

What are some signs of prescription fraud?

Let’s start with patients. One major tip-off is the type of medication they receive:

  • Do they have prescriptions from many different doctors for a mix of prescription painkillers, opioids and tranquilizers?
  • Are they frequently traveling to pharmacies far from their home?
  • Are they showing signs of running through medication too quickly, such as seeking a refill for a month-long supply after only two weeks?

When looking at physician patterns, red flags include doctors that dole out suspiciously large volume of prescriptions — sometimes in the millions — for opioids, narcotic painkillers and tranquilizers to patients without a diagnosis of pain problems or other conditions.

How is prescription fraud linked to the opioid epidemic?

Opioids are highly addictive medicines that include prescription painkillers and illicit substances such as heroin. Many people get hooked on opioids after receiving a legitimate prescription following an injury or surgery. They try to obtain more prescriptions for the medicines, and may turn to buying heroin on the street if they are unable to get access to prescription opioids.

As prescription opioid use has soared, so has heroin use. In 2012, doctors prescribed 259 million bottles of opioids, one for every adult in the country. Meanwhile, the number of heroin users skyrocketed over the past 15 years. The majority of new heroin users say they were addicted to prescription opioids first.

What are some solutions to prevent prescription medicine fraud?

Analyzing medical claims often yields clues to prescription fraud. Insurers can help cut back by identifying patients and prescribers who engage in questionable practices. For example, at some Blue Cross and Blue Shield Plans, warning bells go off when members obtain 10 or more prescriptions for controlled substances in a three-month period, or visit three or more prescribing doctors or three or more pharmacies. Blue Cross and Blue Shield Plans then assign a case manager to work directly with these patients to help distinguish individuals who are responsibly managing their pain from those who are abusing medications and may need help.

Blue Cross and Blue Shield Plans also work closely with law enforcement to monitor doctors who prescribe high levels of narcotics and other controlled substances.

Fraud abuse 2
Breakdown of prescription drug fraud by type: The greatest amount of fraud is contributed by drug-seeking behavior such as addiction — 64%. The others are 13% identity theft, 11% forged prescriptions, 9% duplicative/inappropriate therapy, and 3% other.

How do law enforcement and healthcare organizations work together to detect prescription medicine fraud?

Health insurance companies and law enforcement officers are important partners in the fight against prescription medicine fraud. Since insurers have access to data from millions of claims, they are often the first to spot suspicious behavior from doctors or pharmacies and can inform law enforcement.

In one case, a Blue Cross and Blue Shield Plan noticed that a physician had set up a pharmacy in his office and was prescribing a high volume of opioids, tranquilizers, muscle relaxers and other controlled substances. Plan officials conducted a full audit of the doctor’s records and found numerous irregularities, such as prescribing several powerful medicines to the same patient – a potentially deadly combination. The doctor assigned vague diagnoses to patients and did not refer them for other pain management treatments. The Blue Cross and Blue Shield Plan filed a complaint with regulatory agencies and the doctor is being investigated by the DEA.