Express Scripts Offers New Fraud Program


Express Scripts, Inc., a national pharmacy benefit management company, has established a comprehensive fraud, waste and abuse (FWA) detection program for workers' compensation payers designed to help stem the rising costs associated with the widespread abuse of prescription narcotics.

The 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.

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.

The program 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.

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) 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.

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