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Doctor Shoppers ? Not all of them….or are they ?

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Let’s begin with a story – A patient consults a physician for a particular chronic ailment; buys a controlled drug based on the physician’s prescription; not satisfied with the results, visits multiple physicians; gets multiple prescriptions on scheduled drugs, but still in vain. In this case, irrespective of whether the patient gets pain relief or not, the Drug Enforcement Administration (DEA) is highly likely to blacklist that person (as a “Doctor Shopper”) and deny any further prescriptions from physicians. Where-ever the patient goes, the information is likely to follow.

Does this story sound familiar to you?
Not that you are Doctor shopping but DEA is very stringent about such suspicious activities. Though the intensity varies from one State to another, blacklisting does restrain the patient / beneficiary from receiving hassle-free treatments.

What is Doctor Shopping?

It is the practice of visiting multiple physicians to obtain multiple prescriptions for otherwise illegal drugs, in-turn using them for unlawful activities. Most often, the term “Doctor shopping” is associated with obtaining controlled drugs using multiple prescriptions and selling them in the black market.

But, we all know that not all those who visit multiple doctors for scheduled drugs are doctor shoppers? Don’t we?

Here is a classic case

A patient in Texas was suffering from severe back pain and was under controlled substance medication (Loratab 10/500) for 10 years based on her primary care doctor’s prescription. Later, she moved to Florida where she couldn’t find a doctor who would prescribe the same drug with similar dosage (150 tablets a month). So, she visited multiple doctors to ensure that she had enough supplies required on a monthly basis, thus matching her Texas doctor’s prescription numbers. After a couple of months, the pharmacies denied her tablets, the doctors denied her any more prescriptions. Without an option, she had to quit her drug dosage. That’s not the sad part. Exactly after 9 months, she was arrested for Doctor shopping 3rd degree felony. The patient lost her job and peace, leave alone health.

Such cases, where genuine patients are being held for Doctor Shopping frauds, are not uncommon across the States, but, the fact that there are real Doctor shoppers out there selling scheduled drug supplies in the black market, cannot be overlooked. In many cases, the States do not have information about the history of the beneficiary, especially if the beneficiary is from another State and hence the victimization. But, this is a double-edged sword. Since the State do not have the track record, it is easy for the fraudsters to penetrate the system and take advantage, as a beneficiary. Study claims that the average “doctor shopper” costs insurers $10,000 to $15,000 a year because of fraudulent use of medication

For example: Evidence in one of the Illinois court showed that a (convicted) Medicaid beneficiary submitted false claims for Medicaid home health care services claiming that her daughter, who she falsely represented was her niece, provided services that were never performed. When questioned about the false billing, she had lied to the investigators.

What it takes for a fool-proof Medicaid system

Whether a beneficiary has been blacklisted by DEA, OIG or accused of Doctor Shopping charges, it is for the State Medicaid agency to ensure that only genuine beneficiaries get into the system. Otherwise, the system is bound to lose Millions of $ every year on account of beneficiary frauds.

The Medicaid system should be well-equipped with the history of beneficiaries, their associations, pattern of transactions, their income and assets and accordingly earmark them based on risk scoring for fraud. Also, they should be constantly monitored for any first occurrence of suspicious activities and accordingly adjusting their scores from time-to-time. Not just that! this risk-scored profiling of the beneficiaries should be made available to all the States at any point in time. The State database should be linked with the Federal ones in order to ensure that across the country, the information about the beneficiary is accurate and to date.

Beneficiary Fraud – Is that all?

Definitely not. While this may put a check on Doctor shopping fraudsters from entering into Medicaid and other Health payer systems, the Beneficiary fraud in itself is a mammoth to control. Some of the categories under Beneficiary fraud are eligibility fraud, card sharing, drug diversion, etc. Preventing beneficiary fraud requires a strategic effort by the Medicaid /Health payer enterprises that may range from gradual enhancement of existing complex processes to bringing in next-gen intelligent beneficiary profiling systems.

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