YELLOW SHEET Office of the State Auditor of Missouri Claire McCaskill

April 18, 2002

Report No. 2002-29

State Medicaid program cannot quickly identify or prevent potential abuse by  prescription drug recipients 

Missouri paid $272 million (40 percent of the $681 million total drug cost) to fill prescriptions for 420,000 Medicaid recipients in fiscal year 2001.  While many recipients received these prescriptions for legitimate medical needs, the state program cannot assure the necessity of all these expenditures.  Auditors found signs of controlled substance abuse in the state program and ineffective controls to timely identify or prevent such activity. 

Recipients visit multiple doctors, pharmacies for prescriptions 

More than 3,900 Medicaid recipients over two fiscal years (2000 and 2001) visited 5 or more prescribers and obtained $8.7 million in tranquilizers, painkillers and opioids.  In some cases, several doctors in the same medical group treat recipients, which can justify some multiple prescribers.  But auditors also found at least 10 recipients who, in one year, visited 19 to 53 doctors, and up to 25 different pharmacies, for prescriptions.  Prescription drug industry experts have said recipients addicted to such drugs see several doctors (known as “doctor shopping”) and use numerous pharmacies to support and disguise their habit.  (See page 4) 

More than a year passes before program stops potential abusers 

Program officials, since January 2000, have identified 400 recipients potentially abusing prescription drugs.  But officials often took up to a year before restricting recipients to one prescriber and one pharmacist to curb diversion.  In one case, a potential abuser identified in April 2000 was still unrestricted 21 months later.  This recipient visited four prescribers and obtained 40 controlled substance prescriptions since identified.  (See page 7) 

Pharmacies are not forced to deny an overlapping narcotics script 

The program automatically notifies pharmacies when a recipient requests another controlled substance in the same therapeutic class or within overlapping time periods.  But the program does not deny claim payment and the pharmacy can override the alert.  Many patients have a valid need for drugs in the same therapeutic class, such as a terminally ill patient who takes both pain relief and anti-anxiety drugs.  But auditors also found patients with potentially invalid usage patterns.  One recipient went to 10 prescribers and obtained 26 prescriptions in 90 days of oxycodone- based drugs, considered of high potential abuse by the Drug Enforcement Administration (DEA).  Although pharmacists received 17 automatic alerts on this recipient indicating overlapping prescriptions or therapeutic duplication, the prescription were filled, and the claims paid.  (See page 5)   

State program responds with restrictions to some increasingly abused prescriptions  

Program officials realize recipients’ potential misuse of Oxycontinâ, a drug increasingly abused and at the center of current Attorney General Medicaid fraud investigations.  Several other states have limited the amount of Oxycontinâ obtained by Medicaid recipients. 

Oxycontinâ is legitimately prescribed to patients suffering intractable pain, but the DEA has also seen illicit sales of the drug rise, with prices up to $80 a tablet.  Auditors noted the number of Oxycontinâ prescriptions in Missouri increased 64 percent between fiscal years 2000 and 2001.  In addition, state Medicaid fraud investigators are looking into five recipients obtaining Oxycontinâ for potential sale.  (See page 15) 

Oxycontinâ’s manufacturer has worked with states to institute a “hard edit” on the drug, which blocks payment when Oxycontinâ prescriptions exceed certain guidelines.  State officials said systems should be in place by mid-April to allow similar maximum daily quantity edits.  (See page 18)

Complete Audit Report