Missouri State Auditor's Office

Improvements made since last audit on oversight of Medicaid prescription drugs, but some recipients still misuse services more than a year without detection

This audit followed up prior recommendations to a 2002 audit which showed the state had inadequate controls over its Medicaid prescription drug program. Since 2002, Medicaid drug costs have doubled to $1.2 billion. This report specifically analyzed if new policies or procedures detected recipients possibly abusing the system and restricted the narcotic amounts regularly received by a recipient. The state program, run by the Department of Social Services - Division of Medical Services, has the ability to "lock-in" a potentially abusing recipient, which restricts the recipients to one prescriber and/or one pharmacy to obtain prescriptions. The lock-in program is meant to curb doctor-shopping practices to obtain excessive amounts of certain controlled substances.

New procedures are steps to curbing OxycontinŽ abuse

In March 2003, division officials added computer controls requiring recipients to have certain diagnoses before approving OxycontinŽ prescriptions. In addition, new controls will also deny OxycontinŽ claims exceeding a recommended dosage for a 24-hour period. In April 2002, auditors reported division officials did not have procedures to restrict recipients visiting multiple physcians to obtain painkillers - specifically OxycontinŽ - which is an increasingly abused drug. (See page 4)

Some recipients abused plan for years without detection

Auditors again found recipients who abused the program for a year or more without detection. Division policy allows a recipient to use four or more pharmacies and five or more physicians to obtain prescriptions before they are targeted as a potential system abuser. Auditors found division staff did not review a quarterly list of potential abuses until the data was 6 to 12 months old. One recipient visited from 5 to 16 doctors per quarter over a

21-month period. (See page 7)

Recipients not restricted if they

only see multiple doctors

Auditors found division officials do not restrict recipients who obtain drugs from multiple prescribers, but just one pharmacy. Instead, division officials said they restrict recipients who do both - visit multiple prescribers and multiple pharmacies - assuming these recipients are more likely to potentially abuse the system. But auditors found a need to also consider restricting recipients visiting multiple prescribers. Auditors found examples of recipients seeing between 5 and 20 prescribers every three months. (See page 8)

Some restricted recipients not reviewed for two years

Auditors found recipients restricted to the lock-in program still received controlled substance prescriptions. For example, auditors found 45 recipients visited an average of 13 prescribers while under the lock-in program restrictions. Division officials set a standard lock-in period of two years, but do not review a recipient's activity until after the two-year period. (See page 8)