Drug Diversion and Health Care Fraud

OCTOBER 01, 2004
Cmdr John Burke

Prescription drug abuse in America, although nothing new, continues to be one of the most prevalent forms of abuse in this country. Although there are a variety of ways to divert and abuse pharmaceuticals, the abuse of health care insurance seems to remain a popular method.

Well over a decade ago, my investigators encountered a woman who was seeing 69 doctors at the same time. She was swindling them out of diazepam and hydrocodone products, all while covered by one national health care insurer over an 18-month period. She was using over 20 pharmacies, and she bilked her insurance company out of more than $80,000 in bogus doctors' visits, procedures, and prescription drugs. At that time, employees at this national health insurer had no clue that this person was fraudulently obtaining these services and drugs at its expense. Since then, this and other health care insurers have taken steps to identify this massive form of health care fraud.

"Doctor shoppers" account for a large percentage of the use of health care fraud while committing prescription drug offenses. The average doctor shopper is likely seeing at least 5 practitioners at one time and generating over $10,000 each in health care fraud every year. Although the example above involved private health care fraud, public health insurance by no means escapes the scammers.

Medicaid and workers' compensation programs have long been targets of doctor shoppers, as violators take advantage of the bureaucracy associated with large governmental programs. The absence of safeguards, little or no money to hire investigators and medical reviewers, and the reluctance of reporting these criminals to law enforcement authorities all contribute to the problem.

Many governmental entities that oversee Medicaid and workers' compensation programs are making strides to combat pharmaceutical diversion and health care fraud. Suspected violators can be restricted to one pharmacy for their drugs, although frequently little or nothing is done to prosecute these oftentimes felony drug offenders.

The best means currently available to combat these crimes is for states to develop and use a prescription-monitoring program. The program needs to include all controlled substances and to provide law enforcement with access to the information in order to investigate and vigorously prosecute those committing drug diversion and related health care fraud crimes.

With health care insurance rising and continuing to be a constant political issue nationwide, everything possible needs to be done to reduce the financial damage. Private and public insurers need to continue to improve the monitoring of those who are seeing multiple practitioners and pharmacies in order to illegally obtain prescription drugs.

Health care professionals need to continue to improve their diligence in dealing with prescription drug seekers. These criminals must be identified and reported, if those addicted to these substances are to receive opportunities for rehabilitation, and if those trafficking in drugs are to receive jail time.

Last, but not least, my peers in law enforcement need to make prescription drug abuse and health care fraud their highest priorities. Nationally, health professionals are frustrated every day because of law enforcement's apparent lack of concern for pharmaceutical diversion. As I have mentioned many times, cooperation is the key to putting a significant dent in this national drug problem.

John Burke, director of the Warren County, Ohio, drug task force and retired commander of the Cincinnati Police Pharmaceutical Diversion Squad, is a 32-year veteran of law enforcement. For information, he can be reached by e-mail at burke@choice.net, via the Web site www.rxdiversion.com, or by phone at 513-336-0070.