Vision Session: U.S. Office of Inspector General - From Analytics to Action: A Law Enforcement Perspective on the Use of Data Analytics to Combat Rx Drug Diversion
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1. From Analytics to Action
A Law Enforcement Perspective on the Use of Data
Analytics to Combat Rx Drug Diversion
Gary Cantrell
Deputy Inspector General
Mike Cohen
Inspector
U.S. Department of Health and Human Services
Office of Inspector General/Office of Investigations
2. Overview
• HHS-OIG Overview
• Use of Data Analytics
• Prioritizing Enforcement through Data
• Rx Data Analytics
• Rx Drug Fraud Trends in Medicare/Medicaid
• Case Example – Pharmacy Scheme
• Measuring Impact
3. Program Scope
• CMS is the largest purchaser of health care
in the world – approximately $802 billion
• Medicare, Medicaid, and Children’s Health
Insurance Program provide care for
approximately 1 in 4 Americans (roughly 107
million beneficiaries)
• CMS processes more than 1 billion Medicare
claims annually
4. HHS Office of Inspector General
• Mission: Protect the integrity
of HHS programs as well as the
health and welfare of program
beneficiaries
• Fight fraud, waste, abuse in
Medicare & Medicaid, plus 100
other HHS programs
• Largest Inspector General’s
office in Federal Government
• Office of Investigations
performs criminal, civil and
administrative enforcement
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6. How do you prioritize enforcement
in a program so large?
7. Data Analytics
• Data analytics plays a significant role
in OIG’s oversight and enforcement
strategy
–Allocate Resources
–Triage Allegations
–Investigations are more efficient
–Measure Impact
12. Pharmacy model
Metro area distribution of the 1,000 pharmacies with the highest risk scores
0 50 100 150 200 250 300 350 400 450
Miami
New York
Los Angeles
Detroit
Houston
Tampa
McAllen
Dallas
Number of pharmacies
13. Prescriber model
Metro area distribution of the 1,000 prescribers with the highest risk scores
0 50 100 150 200 250 300 350 400 450
Miami
New York
Detroit
Los Angeles
Atlanta
Tampa
Phoenix
Houston
Number of prescribers
14. Prescriber “pill-mill” model
Metro area distribution of the 1,000 prescribers with the highest risk scores
0 10 20 30 40 50 60
Nashville
DC/Baltimore
Atlanta
Philadelphia
New York
Phoenix
Detroit
Seattle
Number of prescribers
16. Recent OIG Drug Reports
• Inappropriate Medicare Part D Payments for
Schedule II Drugs Billed as Refills
– Inappropriately paid $25M for schedule II refills
– Pharmacists putting “dummy numbers” or pharmacy number
rather than prescriber number: “AB0000000”
• Prescribers with Questionable Patterns in Medicare
Part D
– 736 general care physicians
– Medicare paid $352M for part D drugs from these physicians
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17. Recent OIG Drug Reports
• Retail Pharmacies with Questionable Part D Billing
– Over 2600 pharmacies identified
– Found 873M prescriptions written for 24M benes
• Medicare Inappropriately Paid for Drugs Ordered by
Individuals Without Prescribing Authority
– Massage Therapists, Athletic Trainers, Home Repair Contractors,
etc.
• Part D Beneficiaries With Questionable Utilization
Patterns for HIV Drugs
– Almost 1,600 Part D beneficiaries had questionable utilization
patterns for HIV drugs.
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DHHS/OIG
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19. OIG Purview
• All drugs billed to Medicare, Medicaid
• This includes Controlled and Non-Controlled
medications
• Non-Controlled very expensive
• Used as bargaining chips
22. Why Worry About Non-
Controlled?
• Used illicitly by themselves
– Antipsychotics (“jailhouse heroin”)
– HIV medications side effects (e.g. Sustiva)
• Used as “potentiators” for opiates
25. Case Example
• Detroit pharmacist (Babubhai “Bob” Patel) owned 26
pharmacies
• Provided kickbacks to induce physicians to write
prescriptions and present them to his pharmacies
• Pharmacist/owner arrested and sentenced to 17 years
• 26 Defendants Originally Charged
– 20 Convicted or Pled Guilty, including
• 11 of 12 Pharmacists
• 2 of 4 Doctors
• 13 Additional Defendants Charged
– Including 5 doctors, 4 Pharmacists, and a Home Health Agency
owner
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29. Outcomes: DME Payment Trends
• Medicare payments for DME in Miami
peaked at more than $60 million per
quarter in 2006
• In 2007, numerous federal oversight and
administrative initiatives were launched
by CMS, OIG and others, including the
Medicare Fraud Strike Force in May 2007
• Miami-area DME payments decreased
from over $40 million per quarter in 2007
-before the Strike Force’s first takedown-
to $15 million per quarter in 2011 (e.g.,
approximately $100 million in annual
savings thereafter)
Sustained declines in Medicare payments have followed Federal enforcement and oversight action.
30. Outcomes: HHA Payment Trends
• Medicare payments for Home Health
care increased from 2006 until 2010
• In 2009, federal enforcement actions
(initiated by the HEAT Strike Force case
U.S. v. Zambrana in Miami), followed by
the OEI HHA Outlier Payments report,
influenced CMS to change Medicare’s
HHA outlier coverage policy
• Since 2010, Medicare payments for home
health care nationally decreased by more
than $300 million per quarter (e.g., more
than $1 billion annually)
– In Miami, payments for HHAs decreased by
$100 million per quarter since peak in 2009
– In Dallas and McAllen, TX, payments for
HHAs are down by $30 million per quarter
– In Detroit, payments for HHAs decreased by
$25 million per quarter since peak in 2009
Sustained declines in Medicare payments have followed Federal enforcement and oversight action.
31. What To Do if you Suspect Medicare
Fraud or Diversion Activity?
If you suspect a Medicare
provider or beneficiary is
diverting, contact
• 800-HHS-TIPS or at
• oig.hhs.gov/report-fraud
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