Combating Fraud and Prescription Drug Abuse

Prescription drug overdoses in the United States claim the lives of more than 15,000 annually. Each year, prescription drug overdoses account for a shocking 1.2 million visits to the emergency room.  Abuse of these highly addictive narcotic drugs is regarded as potentially more deadly than heroin and cocaine combined.  Unfortunately, many prescription drugs are obtained fraudulently to support an addict’s habit.  Whether these ill-gotten drugs are obtained from pill mills, forged prescriptions, “phantom pharmacies” or through the pharmacy fraud of organized crime, the consequences tend to be the same—all of us pay for prescription drug fraud.

 The Cost of the Prescription Problem

Prescription drug fraud and abuse is estimated to cost the US healthcare system up to $224 billion dollars annually.  The monetary cost doesn’t even take into account the human suffering or the overburdening of the healthcare system, its administration and the potential consequences of actually failing to meet the legitimate needs of those individuals not engaged in fraudulent activities.

According to the Coalition Against Insurance Fraud (CAIF) the diversion of prescription drugs is a defining drug crime in the US today, without equal in its enormous size, pace of growth, its barriers to deterrence and the magnitude of its harm to people from all walks of life.  Additionally, upwards of 20 million American were projected to be caught-up in abusing prescription drugs by the year 2007.  That number was nearly 7 years ago, and the US continues its battle with the escalating problem of prescription drug abuse today.

Some statistics from the CAIF site give harsh insight into the magnitude of the problem we face, and give us an estimate of the effort and resourcefulness demanded of us to create and implement effective solutions.

  • Every 14 minutes, a person is killed by drugs.
  • In the US, Narcotic painkillers (opioids) are the cause of more deaths by overdose than cocaine and heroin combined.
  • In 2011, drug-caused deaths outnumbered traffic fatalities, concurrent with the rise in prescription drug abuse.
  • There were enough prescription painkillers sold in the US by 2010 to dose every single adult American with a “5 mg dose of hydrocodone every four hours” for a full month.
  • Drug diversion (the crime of diverting licit drugs for illicit purposes) costs private insurance plans upwards of $857 million dollars every year.

Measures to Combat Prescription Fraud

One key means by which to combat fraud and prescription drug abuse is through the watchful management of the Medicare prescription drug program.  According to CMS (Centers for Medicare & Medicaid Services) Principal Deputy Administrator, Johnathan Blum, his agency takes drug abuse “very seriously”.  The CMS actively works on the detection and prevention of drug fraud and abuse in an effort to protect the Medicare program itself, as well as its beneficiaries—the American taxpayers.

As part of Medicare Part D, legitimate prescription drug benefits provide coverage to upwards of 39 million American seniors.  The CMS works to ensure that these legitimate beneficiaries of prescription drug coverage receive the prescriptions needed while simultaneously remaining vigilant to ensure this part of the Medicare program is protected from fraudulent use.

The current strategy in use to stem Medicare Part D prescription drug fraud and abuse is to identify enrollees in the program who have potential “overutilization issues” which could put a patient at risk.  The “overutilization” of narcotic painkillers (opioids) or acetaminophen products is capable of causing serious and adverse side-effects, including death by overdose.

In 2013, the CMS implemented the Medicare Part D Overutilization Monitoring System.  It is designed to assist the CMS in ensuring the those sponsors participating in the Part D plan meet the CMS requirements of establishing “reasonable and appropriate” management programs preventing the abuse (overutilization) of these drugs.

In comparing the 2011 statistics which pre-dated the implementation of the monitoring system, there was an almost 60% reduction in Medicare Part D enrollees flagged as potential abusers of opioids or acetaminophen in the first 6 months of 2013.  Such a significant decrease definitely is encouraging to those seeking to gain some control over the crime of drug diversion and the  scourge of escalating prescription drug abuse.


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