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Opioid SuicideNo more Mr. Niceguy. It started as “better guidance” for prescribers as concerns mounted that the over-prescription of opioid pain medications was feeding a sharp rise in addiction to illicit forms, including street-sourced pills and heroin. But it has turned into well-coordinated federal and state enforcement actions against physicians and nurses, as well as their practices and hospitals where they practice. Here are the key lessons The Greeley Company has learned from performing external peer review of pain management cases.

Takedowns, Strike Forces, and Wanted Posters, Oh, my…

In June 2018 the Department of Health and Human Services Office of Inspector General (OIG), along with state and federal law enforcement partners, participated in an unprecedented nationwide “health care fraud takedown,” the largest multi-agency enforcement operation in history, with interagency “strike forces” mobilized nationwide.

While the strike forces’ enforcement actions were not solely related to opiates, they clearly had pain med prescribers in their sites. In the last year, “OIG has issued 587 exclusion notices to individuals and entities whose conduct has contributed to opioid diversion and abuse. These notices bar participation in, or submitting claims to, all federal health care programs, including Medicare and Medicaid. Among those issued exclusion notices were 67 doctors, 402 nurses, and 40 pharmacy services.”

Beyond sending a “strong message” to those who would prescribe inappropriately and have the federal government foot the bill for the Medicare and Medicaid prescriptions, plus the long-term costs of treating addicts, the OIG sees these enforcement actions as “an excellent investment.” The current tally has OIG recovering $4 for every $1 spent on the investigations.

It’s best to do your own periodic review for appropriateness of pain treatment rather than waiting for the OIG to kindly do it for you.

If you didn’t get caught in the dragnet of the recent health care fraud takedown, you’re not out of the woods. Greeley recently received a call from the attorney for a physician whose office had just been raided by the OIG, with the officers leaving with hundreds of medical records “of interest” because of pain medication prescribing. The attorney was asking Greeley to review their records to see how much exposure the practice has. Frankly, it’s best to do your own periodic review for appropriateness of pain treatment rather than waiting for the OIG to kindly do it for you. The best way to do this is with ongoing internal reviews mixed with periodic external reviews to validate the necessity and appropriateness of pain management care.

Avoid Being a Target

The OIG sees enforcement as an investment with a 300% return.

Last year the OIG released data related to what they considered to be “extreme use” of opioids among Medicare Part D beneficiaries, as well as “questionable prescribing” patterns by providers. While it is eye-opening to read the entire report, there are some key takeaways hospitals and practices should consider when evaluating medical necessity and looking for patterns that put patients at risk for addiction or overdose, and providers and the organizations that extend them privileges at risk for enforcement actions.

In March 2016 the Centers for Disease Control issued Guidelines for Prescribing Opioids for Chronic Pain. Cumulative annual patient prescriptions and patterns of prescribing that color outside these lines are red flags. Consider using this two-page fact sheet during case review as a short-form reminder of what is considered reasonable and appropriate.

Other areas of concern that can be red flags include:

  • Excessive dosing and frequency
  • Use of multiple different narcotics
  • Refills without adequate follow up
  • High frequency of pain management procedures
  • Failure to conduct repeated trials to wean off chronic opiates
  • Inadequate use of alternative treatment modalities
  • Inappropriate management of prescribing/refills by nurses and office staff
  • Poor documentation

Perhaps the most suspect of cases hospitals and practices should be on the lookout for are profitable sidelines. The OIG made an example of a cardiologist who had, in essence, switched to pain medicine because it paid better. Addicts routinely sought him out for prescriptions, which he would gladly provide, but not before some medically unnecessary tests, like EKGs or lung capacity testing, for which he billed.

The monetary risk to hospitals and practices is huge here. When medical necessity is on the table, a small sample guides the give-back. If a certain percentage of sample cases are deemed not medically necessary, that can become the multiplier for the settlement over every instance of that diagnosis or treatment over several years of billing. Remember, the OIG sees enforcement as an investment with a 300% return.

If you would like to discuss how Greeley’s external peer review services can help mitigate your risk for an enforcement action related to OIG’s laser focus on medical necessity, including the opioid crisis, let’s start the conversation.



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