Monday, February 21, 2011

Increase in Rx dispensing partial cause of fraud increase?

In a recent study done by NCCI Holdings found a “dramatic increase in the portion of drug dollars associated with drugs dispensed by physicians.” With pain medications being the number one prescribed workers compensation Rx there is no wonder that Oxycontin has grown in popularity. Oxycontin a far relative of morphine still carries with it a addictive component which has raised red flags for an alternative pain management drug. Oxycontin is one of the few prescribed drugs with the warning on the label that it is habit forming. The fact that Oxycontin can be addictive should lead us to believe the doctors prescribing it to our workers comp claimants only increases the chance that it could turn a "normal" claimant to a "professional claimant".

The number one prescribed drug in workers comp is a factor in the repeat offender claimant. Certainly the situation may be far and few between but the occasion has presented itself in Nationwide SIU history several times. There are several key factors, with the help of a pharmacy medical records canvas, that you can key in on. One factor to look for is multiple hits on one pharmacy. For the life of an addict the next time you take the drug is never as good as the first time you take the drug. Your body builds a tolerance and causes you to seek more and more of the drug to try to replicate the first time. In the case of Oxycontin the body does build that tolerance and to achieve that same effect the user finds themselves taking 2 to three times the prescribed amount. This leads the claimant to do one of two things go back to the same pharmacy more often or begin to go to different pharmacies.

Once they realize they only can get so much Oxycontin at one pharmacy they turn to other pharmacies. This brings us to our next factor to look for, multiple pharmacy locations. In previous pharmacy records canvasses we have found claimants that have used up to 8 different pharmacies all within a 20 mile radius of their home. There are several ways a claimant will try to reproduce their prescription but in the end the desperate find a way. The most difficult obstacle the claimant must overcome are the larger pharmacies with area networks that enable them to view prescriptions from other locations. The thing that most people forget is that there are more smaller pharmacies than you think, as well as the vast numbers of larger pharmacies available.
The last factor to look for in possible Oxycontin addicted claimants are repeat offender claims whether for the same injury or same employer. Or if the claimant has multiple claims all with a record of doctor prescribed pain killer use. The "professional" claimant now fakes, stages or lies about injury just so they will be able to get the next dose of prescriptions. The claimant may appear to cooperate and return to work in a timely manor but it is the frequency of claims that adjusters must be aware of.

By using medical records canvases not only can you find the possibility of pre existing conditions but there are certain situations where you will uncover more. The increase in prescribed pain killers and the addictive nature of those prescriptions opens the WC claims to other dangers that you may have never thought of. The use of pharmacy medical records canvasing can bring to light a hidden agenda of your claimant that you may have overlooked otherwise.

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