Preventing Prescription Drug Fraud

Overview of the Prescription Process

The prescription process is a convoluted multistep process to minimize prescription drug fraud and ensure patient safety. According to StatPearls, for prescription filling to be safe and effective, “there needs to be an understanding by the physician of the mechanism and properties of the medication before prescribing, and the pharmacist must be aware of potential interactions the patient may have with their other medications.”

Despite the mechanisms in place to minimize fraud, the procedure still has cracks, allowing fraudulent cases to slip through. Part of understanding how fraud occurs requires an understanding of the prescription process, the stakeholders, and their responsibilities.

Prescribing

The first significant player, besides the patient, is the prescriber, whose role requires writing the prescription that authorizes the patient to get medication. As part of their role, the prescriber must ensure that the patient truly needs the prescribed drug, look for any substance abuse flags, and review the patient’s medication list to prevent interactions or over-prescribing.

StatPearls notes that some drugs are controlled substances, requiring the prescribing physician to hold a Drug Enforcement Administration (DEA) license and the dispensing pharmacists to have a controlled substance license.

The prescriber can write a paper or electronic prescription, depending on the medication, patient, and other preferences. In 2010, the electronic prescribing of controlled substances (EPCS) system was introduced by the DEA, allowing an extra layer of security by minimizing the ability to forge or alter a prescription.

Dispensing

Once the prescription has been written and sent, the filling process can begin. According to Prescription Hope, the first step — input and initial check — is verifying the prescription information. When filling a prescription, pharmacists must validate the patient’s information by confirming factors such as name and date of birth and then validate the prescription by looking at its components.

For a prescription to be considered valid, it must have multiple components, including the following:

• an issue date
• the patient’s name and address
• the patient’s date of birth
• prescribers name, address, and DEA number
• medication name, strength, and form
• prescription quantity
• directions for use
• the number of refills — this may vary depending on the type and reason for the medication
• prescribers’ signature

The next step for pharmacies is the therapeutic check. At this point, the pharmacist will check the prescription itself and confirm that the proper medication is prescribed for the indicated conditions, similar to the provider at the time of prescription. Additionally, pharmacists will ensure that the drug will not cause adverse side effects due to the patient’s medical history, allergies, and interactions with other medications.

According to Prescription Hope, “under this step, if there is an error or confusion in the prescription, inaccuracy of the drugs and doses prescribed, or if the prescription is damaged or so on, the pharmacist may refuse to fill it until the necessary information is confirmed by the doctor’s office.”

Although regulatory measures are in place to minimize confusion early on, approximately 74% of prescriptions requiring clarification are new. StatPearls notes that only 36% of medications requiring clarification were prescribed electronically.

After the input, initial check, and therapeutic check, the pharmacists and pharmacy technicians can begin preparing the prescription.

Prescription Fraud

According to the Centers for Medicare and Medicaid Services (CMS), prescription drug fraud may include drug diversion, which is defined as “the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber (for example, recreation, addiction, or financial gain).” Anabolic steroids, central nervous system depressants, hallucinogens, opioids, and stimulants can be highly addictive compounds, likely targets for drug diversion.

The CMS reveals that there are a handful of prescription drug diversion methods, including the following:

• selling prescription drugs
• doctor shopping — seeking care from multiple physicians so they can prescribe controlled substances
• illegal internet pharmacies
• drug theft
• prescription pad theft and forgery
• illicit prescribing

Providers and Drug Diversion

Despite common misconceptions, patients are not the only population that can contribute to drug diversion. Many cases have been highlighted that implicate clinicians or prescribers in drug diversion. In a document from the CMS, the organization highlights a lawsuit in 2010 where a physician was writing unnecessary oxycodone prescriptions to patients who then resold them, resulting in 11,000 pills sold and $1 million in Medicaid claims.

Regulatory Causes of Prescription Drug Fraud

There are multiple routes to prescription fraud, many of which are rooted in a lack of regulation in pharmacies. According to Benefits Magazine, most pharmacies must be run by a licensed pharmacist who undergoes multiple years of school and several licensing exams. However, in Florida, pharmacy technicians can own a pharmacy for a small fee after completing a two-week course.

Aside from cases where pharmacy technicians are eligible to own a pharmacy, many states minimally or poorly regulate pharmacy technicians. In states including New York, Pennsylvania, Wisconsin, Delaware, Colorado, and Hawaii, even those convicted of possessing and distributing controlled substances are eligible to be pharmacy technicians, allowing them extensive access to various drugs.

In an article by Susan Hayes, AHFI, CPhT, in Benefits Magazine, she notes, “These vital assistants perform many routine functions within the pharmacy but also are given a wide range of discretion. They have the potential to greatly harm patients since technicians mix compounds and place the appropriate drugs in the vial for patients.”

Minimizing Prescription Drug Fraud

Understanding what prescription drug fraud is and how to prevent it can translate into significant cost savings for payers, alleviating the burdens on the healthcare system. The CMS proposes multiple options for clinical practices to minimize drug diversions. Chief of these options is being cautious with prescriptions, layering prescriptions, and patients who request prescription layering. Part of this caution involves rigorous and accurate prescription documentation and cases where providers opted not to provide a prescription.

Another aspect of protecting drug diversion in clinical practice is ensuring prescription security. Making it as difficult as possible to steal prescription pads and forge medications may require securing paper prescription pads and ensuring that prescriptions are clear. Additionally, providers are strongly encouraged to keep their DEA and license numbers confidential whenever possible. Another step to prescription security is switching to an electronic prescription process; this prevents the risk of manipulating a prescription.

Other suggestions by the CMS include using state prescription drug monitoring programs, referring chronic pain management patients to specialists, communicating with pharmacists and other providers to manage care plans and medication lists, and providing patient education for the proper disposal of medications. Prescription fraud industry members are encouraged to discuss fraud with the PBM, obtain and review claims data, educate members on fraud, send an annual pharmacy benefits statement, and notify legal counsel when fraud is suspected or discovered.

In her article, Hayes concludes, “Prescription drug fraud is now a fact of life that frequently makes the headlines. Perpetrators of these crimes, punishable through federal, state, and regulatory agencies, range from low-level fraudsters to pillars of society such as university trustees, physicians, and pharmacists. Rather than relying on others, plan sponsors, through legal counsel, should take matters into their own hands and make sure their claims and assets are properly monitored.”