The report, Medicaid: Fraud and Abuse Related to Controlled Substances Identified in Selected States, examined Medicaid claims from five states for fiscal years 2006 and 2007. States were selected on the magnitude of Medicaid payments for prescription drugs.
According to the report, 65,000 Medicaid beneficiaries in the five states received prescriptions for the same type of controlled substance from six or more physicians between 2006 and 2007. The majority engaged in "doctor shopping," or visiting 6-10 physicians, to acquire the controlled substances. According to the report, this cost Medicaid $63 million.
The report found that many of the Medicaid patients had justifiable reasons for receiving the prescriptions, such as visiting several specialists or physicians in the same medical group, but others acquired the prescriptions to support addictions to controlled substances or to sell the drugs on the street. GAO also found that Medicaid paid over $2 million in controlled substance prescriptions for FY 2006 and 2007 that were written or filled by 65 medical practitioners and pharmacies barred, excluded or both from federal healthcare programs for offenses such as illegally selling controlled substances. Additionally, the report found, using data from the Social Security Administration, pharmacies filled controlled substance prescriptions of over 1,800 beneficiaries who were dead at that time.
GAO recognized that states are responsible for controlling Medicaid fraud, but the agency made four recommendations to CMS in issuing guidance to states to better prevent instances of fraud related to controlled substances:
- "claims processing systems prevent the processing of claims from providers and pharmacies debarred from federal contracts (i.e., on the EPLS), excluded from the Medicare and Medicaid programs (i.e., on the LEIE), or both;"
- "DUR and restricted recipient program requirements adequately identify and prevent doctor shopping and other abuses of controlled substances;"
- "effective claims processing system are in place to periodically identify both duplicate enrollments and deaths of Medicaid beneficiaries and to prevent the approval of claims when appropriate;" and
- "effective claims processing systems are in place to periodically identify deaths of Medicaid providers and prevent the approval of claims when appropriate."
Read the GAO's report on Medicaid fraud related to controlled substances in five states (pdf).