Express Scripts Unveils New Program to Deter Fraud in Workers’ Comp Prescriptions

Express Scripts, Inc. has established a comprehensive fraud, waste and abuse (FWA) detection program for workers’ compensation payers, which can help stem the rising costs associated with the widespread abuse of prescription narcotics.

The new Express Scripts program offers a suite of services that can identify fake or forged prescriptions, overprescribing, prescriber-patient collusion, and injured worker identity theft or drug-seeking behavior.

“Injured workers who abuse prescription drugs put themselves and others at risk,” said Tim Pokorney, clinical director of workers’ compensation at Express Scripts. “Physicians who facilitate this type of behavior are also adding costs to the system and risk to workers’ compensation payers. Given how common the use of narcotics is in treating workers’ compensation patients, the cost of such abuse can add up fast.

“Existing programs are structured to catch anomalies such as patients with too many prescribing physicians or higher than normal dosage of narcotics. But industry-wide, such programs are not geared toward identifying fraudulent activities. Express Scripts’ new FWA program is designed to do just that.”

Express Scripts already offers advanced clinical programs, such as Retro Drug Utilization Review and ScriptAlert, to identify potentially fraudulent or wasteful drug prescribing and usage patterns in workers’ compensation claims. Combining these capabilities with the company’s expertise in analytics, along with a dedicated team of experts, the FWA program provides payers a new tool to detect and address potential problems. Express Scripts’ team of experts includes registered nurses and pharmacists, attorneys, accredited healthcare fraud investigators, certified public accountants, former law enforcement officers, fraud examiners and internal auditors.

Prescription-drug abuse costs carry a high price tag. Research shows that pharmacy costs for opioid abusers are five to seven times greater than those for non-abusers. The average medical cost for abusers is $12,406 higher than non-abusers. Since opioids make up a large percentage of the drugs prescribed for injuries leading to workers’ compensation benefits, fraud and abuse adds up to tens of millions of dollars of added waste.

Opioid – or narcotic – abuse was responsible for nearly 50,000 emergency room visits in 2006, according to a recent study. In addition, the U.S. Food and Drug Administration estimates that more than 33 million Americans age 12 and older misused opioids in 2007, up from 29 million in 2002.

Approximately 19 percent of treatment expenses for workers’ compensation patients is attributed to prescription drugs. Of this, narcotics are by far the most prescribed group of medication. According to the Express Scripts 2010 Workers’ Compensation Drug Trend Report, narcotics accounted for more than one-third of all pharmacy costs for injured workers.

“Although it is hard to determine the precise amount of fraud and abuse, there is no denying that it is a significant problem,” said Frank Scafidi, public affairs director for the National Insurance Crime Bureau (NICB). “Any program that helps payers identify fraudulent claims and decrease their exposure is a good thing. It helps lower the cost of providing workers’ comp insurance.”

NICB is the nation’s leading nonprofit organization exclusively dedicated to leading a united effort of insurers, law-enforcement agencies and representatives of the public to prevent and combat insurance fraud and crime through various means, including data analytics and investigations. Fraudulent claims, according to NICB, result in higher insurance premiums and also create higher prices for goods and services because of other unnecessary expenses such as production delays, retraining costs and equipment replacement.

The program proactively solicits tips from injured workers, law enforcement officials and other sources. If a prescription is flagged, the FWA team works directly with physicians, pharmacies and the injured worker to verify whether the claim is legitimate. The company’s FWA experts use proprietary software and advanced data analytics to analyze the claim. If a prescription is determined to be fraudulent, the team will provide the payer a report of their findings and suggestions for follow-up actions based on best practices to ensure that the cases are resolved.