In recent years, the opioid epidemic has made a significant impact on healthcare in the United States.
One of the consequences of this crisis is the rise of pharmacy and doctor shopping–the practice of a patient seeking out multiple doctors and pharmacies to write and fill additional prescriptions without the knowledge of other pharmacies or providers. This problem has become so widespread that one out of every 143 patients who were prescribed an opioid painkiller obtained their prescriptions from multiple physicians, according to a recent study.
This practice presents a significant risk to the safety of patients and can create substantial financial costs. To combat doctor and pharmacy shopping, and protect the health of our members, Abarca takes a multi-pronged approach:
- Using advanced analytics. Abarca’s team runs daily audits to identify patients who may be attempting to obtain the same prescription from multiple sources.
- Deploying modern technology. With Darwin, our team is able to identify and respond to suspicious transactions in real-time, implement edits to restrict certain behaviors at point of sale, and conduct analyses after claims have been submitted.
- Analyzing member behavior. Our investigations track specific member behaviors that may indicate pharmacy or doctor shopping. This includes how often or how many physicians or pharmacies a member is visiting, the distance the beneficiary travels to visit the different doctors or pharmacies, if he or she is paying cash for prescriptions, and how many pharmacies he or she is using. This analysis can also consider if a patient is using other drug categories that can potentiate the opioid effect and represent a potential safety risk.
- Looking at the pharmacy. When pharmacy shopping is detected, investigators reach out to providers and gather information about why multiple prescriptions are being written and filled at more than one drug store. We also leverage the Prescription Drug Monitoring Program (PDMP) tool to gather information on opioid claims that are dispensed at the pharmacy but not billed through insurance.
- Identifying potential trends. Connecting individual member behaviors can be the key to unlocking broader trends of fraud, waste, and abuse. For example, we saw a rise in suspicious claims at pharmacies closely located to pain clinics. With that information, we can now designate resources that are focused explicitly on better addressing over-prescribing in these areas.
- Coordinating closely. We work closely with pharmacies, health plans, providers, and regulatory agencies to identify and respond to potential cases of pharmacy and doctor shopping.
In response to an emergency, including the COVID-19 pandemic, government agencies require PBMs and health plans to be more flexible in drug authorization requirements to expand medication access. However, to prevent an increase in fraud and doctor shopping during these relaxed periods, Abarca’s Pharmacy Integrity Team and our Fraud Investigators work closely with local government agencies to ensure that cases are quickly identified and addressed.
Through the combined efforts of the Abarca team and our partners across the industry, critical steps are being taken to address pharmacy and doctor shopping head-on and mitigate the risks for our members and clients.
This blog was written by Ana M. Rivera PharmD, Clinical Programs Manager, and Juan L. Nieves, Pharmacy Integrity Team Leader, at Abarca.