Fighting Rx Abuse One Victim at a Time

Sep 13, 2013
Express Scripts' Fraud, Waste & Abuse team understands the danger of prescription drug abuse and proactively identifies and investigates potential cases.

I always assumed prescription drugs were safe because they were prescribed by doctors. To me, drug addiction meant illegal drugs. I had never equated medication with abuse or addiction.

Then I met a 38-year-old mother of three who was addicted to prescription drugs. At the time, I was lead of the Special Investigations Unit of the St. Louis County Police Department, and we arrested the woman as part of an undercover investigation into a prostitution ring. She had been prescribed narcotics to deal with pain after a car accident and this had led to dependency. When we interviewed her, she pleaded for help.

I was stunned to realize that prescription drugs could lead to the kind of addiction that would make someone risk everything – their life, liberty and family. I wanted to help her and others in her situation.

Now, as part of the Express Scripts Fraud, Waste & Abuse team, I can.

Our research shows that 64% of all patient-related fraud is from drug-seeking behavior. Fortunately, cases like that are in the minority, but someone addicted to prescription drugs will go to extreme lengths to feed their addiction. One of the missions of the FWA team is to identify such cases early and get patients the help they need.

Identifying and Investigating Potential Abuse

Our FWA team has diverse backgrounds and experiences. The team includes nurses, pharmacists, pharmacy techs, investigators, auditors and – like myself – former members of law enforcement. With our combined experience and Express Scripts’ proprietary data analytics, not only are we able to identify behavioral red flags and potential cases of drug abuse early in the process, but we leverage our combined experiences to improve case outcomes.

After a case is identified through proactive data mining, we conduct an extensive investigation, including patient, physician and pharmacy verifications as well as onsite pharmacy investigation. If we have enough evidence to substantiate the case as fraudulent or abuse-related, we refer and consult with our clients on follow-up steps along with recommendations for intervention. Referrals can sometimes result in law enforcement action and prosecution, but most often we recommend case management and other programs such as physician and pharmacy lock-in, which requires the patient to use a predetermined physician and pharmacy.

Leading the Way

Express Scripts leads the way in the fight against prescription drug abuse, and we collaborate closely with our internal stakeholders, clients, physicians, pharmacies and government agencies to reduce the potential of fraud and abuse in their prescription benefit programs.

Author Bio

Rick Battelle
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