Fraud, Waste and Abuse

Transcription

1 Fraud, Waste and Abuse CT - Fraud Hotline submitted by Connecticut The Fraud Hotline at the Department of Social Services (DSS) is a proactive approach to handling complaints regarding fraud and abuse from the community. Complaints received by the fraud hotline are sent to the pharmacy unit at DSS to determine if patients should be placed into selected review for further action. If an individual is arrested for illegally obtaining controlled substances by fraud &/or possession of narcotics, hallucinogens, etc., they are upon discovery immediately enrolled into the pharmacy lock-in program. Corrective Managed Care Program submitted by Maryland The Corrective Managed Care (CMC) Program has been instituted by the Maryland Medicaid Pharmacy program to monitor and promote appropriate use of controlled substances. The CMC program is particularly concerned with the prescribing practices and utilization of opioids and benzodiazepines. Through a monthly review the state identifies Maryland Medicaid recipients who appear to be on duplicate drug therapy, visit multiple prescribers writing for similar medications, and/or patronize multiple pharmacies. The CMC program shares this information about potential drug misuse with the respective recipient prescribers and pharmacy providers. Physicians and pharmacies are asked to intervene. If despite the best efforts of the prescriber and pharmacy, there still continues to be overutilization of a substance by a recipient, a recipient can be locked-in to a single pharmacy. Under a Lock-In pharmacy agreement, the recipient will be required to fill the related medications at one predetermined pharmacy. Providers can also recommend candidates to the MMPP for lock-in review by using a referral form that is posted on the MMPP website. The CMC Program utilizes the Corrective Managed Care Advisory Committee, which is part of the DUR Board, to assist with the review of individual recipients and help set policy regarding efforts to reduce the potential misuse of controlled substances. The Committee meets just prior to the regular quarterly DUR Board meeting and includes all members of the DUR Board. For those recipients where contact with prescribers through means of intervention letters has not changed behavior, the CMC Advisory Committee reviews each recipient s drug and diagnosis history profile. The Committee then advises the MMPP on recommended corrective action, which may include lock-in, further provider education or continued follow-up. The ultimate goal of

2 locking in a recipient and of the CMC program is to ensure that recipients have access to education they need while reducing the harm associated with over-utilizing controlled substances. Stimulants and Opioid Controls submitted by Delaware As a Drug Utilization Review (DUR) initiative, DMMA focused on the abuse potential of short acting stimulants in the adult population and the encouragement of doctors to write for the lessabuseable longer-acting stimulants. While different adults respond differently to various medications and a full range of medications needs to be available for appropriate treatment, short-acting stimulants are more often misused, abused, or illegally sold or purchased as a drug of abuse. The risks for abuse of prescription and illicit stimulants are elevated among individuals being treated for attention deficient hyperactivity disorder (ADHD) with increased potential for "diversion" due to the possible euphoriant effect or the improvement of study skills. Prescription agents abused most often are those with pharmacokinetic characteristics that provide a rapid rise of dopamine and serotonin while the longer-acting stimulants often have lower abuse potential and less street value. Prior to any interventions or policy changes, 61% percent of the DMMA adult population taking medication for ADHD was on short acting stimulants. Delaware was also very high in terms of per captita dispensing of amphetamines and stimulants. DMMA, on the recommendation of the DUR Board, began to require adult patients to try and fail a long acting ADHD medication before use of a shorter acting one would be approved. Longer acting medications also have the additional advantages of improved compliance, less peak-trough effects that can be seen with twice or thrice daily dosing of immediate-release ADHD medications on dosing, as well as the reduced potential for drug diversion. The DUR board approved an educational letter on the use of ADHD medications and the need for a trial of a long acting medication. The letters were sent to 292 physicians who prescribe CNS stimulants in Delaware as well as medication profiles for their relevant patients, representing 732 clients. A response form was included in the mailing giving the physicians a chance to give us feedback on the following: what they thought of the clinical aspects of intervention, whether the patient had tried and failed a long acting medication before, and if that was why the patient was currently on a short acting stimulant. Within two months of the intervention letter and policy implementation, the percentage of ADHD clients on a short acting stimulant dropped to a total of 42%. This number will continue to decrease in Delaware and further progress will be reported in future DUR reports. New monthly opioid analgesic quantity limits changes were another initiative of DMMA. This policy coincided with the increased focus on the epidemic of prescription drug abuse in Delaware. It was enacted to improve the medical management of pain patients being treated chronically and to ensure checks are available for the patient before any questions of dependence or abuse are raised. While prior authorizations have been in place for some time for long acting medications along with a total quantity limit of 200 units per month for short and long acting

3 narcotics combined, no prior authorization or pain contract was needed for short-acting narcotics that were under the quantity limit. An increasing number of Delaware chronic pain patients were being treated long term with only high dose, high quantity, short-acting medications. This included getting the highly abuseable and diverted oxycodone 15mg and oxycodone 30mg tablets. Individuals with chronic pain who are being treated with frequent doses of short-acting opioids on a regular basis can develop intermittent withdrawal symptoms between doses of medications which may act to increase pain. These patients who increase opioid doses in order to achieve pain relief may actually be treating opioid withdrawal while longer acting opioids have steady serum levels so mini withdrawals or rebound reactions do not occur as often. Without a prior authorization in place there were no requirements by Medicaid to have controls in place to ensure appropriate treatment, evaluation, and monitoring of these patients. In accordance with the Delaware Board of Medical Licensure discipline guidelines, it was recommended that the current policy be tightened to ensure that these drugs were being used appropriately. New quantity limits were put on highly abuseable short acting medications. Clients now are able to get oxycodone immediate release under the following quantity limitations: oxycodone 15mg maximum of 240 capsules a year, oxycodone 20mg maximum of 120 per year and oxycodone 30 mg maximum of 60 capsules per year, after which a prior auth must be submitting including a pain management contract, pain assessment charts, and documentation of pill counts, and random urine screens. For clients currently getting greater quantities, titration to a longacting opioid medication was required with decreased utilization and frequency of the short acting medication or a rotation to a different short-acting opioid for breakthrough pain that would allow for less frequent dosing and utilization. Exceptions were made for clients being treated for cancer and these patients still have these medications available to them without prior authorization if they have an applicable diagnosis on their medical file or have one submitted on the prescription. Since implementation, there has been a transition to more clients being treated for chronic pain with longer acting medications. On prior authorizations submitted, patients were appropriately converted to long acting medications while the shorter acting medications were subsequently decreased and lowered. There has also been a decreased utilization in short acting narcotics in the 5 months since this policy was initiated. Further decreases are expected as people use up their yearly quantity limit of oxycodone and as awareness increases of the issues surrounding use of high doses and high quantities of narcotics chronically. Since this implementation was very successful and because chronic use of opioid medications has risks and should be monitored with a pain contract and urine screens, DMMA also recommended further restrictions on the criteria on short acting narcotics and further tightening up criteria to ensure abuse won t just shift to other drugs. Currently patients can get 2400 units of lower potency narcotics per year without a prior authorization and without any requirement

4 for a drug urine screen or pain contract. For someone with an addictive tendency, by the time the narcotic quantity used exceeds this threshold; it would be too late to prevent the addiction. As such, it was recommended that all short acting opioid analgesics move to a quantity limit of 120 a month with a yearly quantity limit of 720 triggering the need for a prior authorization to be submitted with a pain contract and documentation of drug screens. After 6 months of 120 tablets a month of a short-acting narcotic, a condition would be considered chronic and should be treated with a long-acting narcotic. The Board approved the recommendation and implementation was planned for July Methadone Edits submitted by New Jersey Another innovative solution implemented by DMAHS and Molina Medicaid Solutions demonstrates the informative relationship that can exist between pharmacy claims processing and medical claims history. New Jersey FamilyCare (NJFC)/Medicaid policy limits payment of claims for Methadone to pharmacies based on this drug s intended medical purpose. Pharmacies are eligible to receive NJFC/Medicaid payments for Methadone when this drug is prescribed for pain management. However, when Methadone is prescribed for the treatment of substance abuse, pharmacies are not eligible to receive payment. For the treatment of substance abuse, Methadone is provided by drug treatment centers and is considered a clinic service. To support the Methadone Edit, clinic claims reflecting payments for Methadone are downloaded to the point-of-sale (POS) system. During POS processing, this information is referenced to determine if a conflicting clinic claim for Methadone on or about the service date of the pharmacy claim is found. If a conflicting claim is found, the pharmacy claim is denied for prior authorization. Development of a Prior Authorization Required Process for Medications without prospective DUR edits submitted by Montana In an effort to combat significant medication overuse/abuse and support patient safety, the pharmacy case management program worked with the department to develop and implement a process for a provider-driven PA required process managed through the point-of-sale system. This process is for medications normally not requiring prior authorization and clients for this program are referred on a case-by-case basis. Implementation of a Drug Not Covered Status in the PDCS/X2 system prevents a client from receiving a selected medication or complete therapeutic class of medications each time a claims is submitted, unless a prior authorization is granted per instructions developed by the provider and the case management pharmacist. Currently approximately 200 patients are enrolled and monitored through this program.

5 This has been an effective means to provide a higher level of management for those patients for who even the lock-in program cannot prevent overuse and misuse of medications. This program has been in effect since FFY 2005.