They're Watching You


If you are prescribed any type of controlled substances from a physician, your name is on a database somewhere – pharmacy, insurance company, possibly a state database. When you start filling more prescriptions for controlled substances than average, your name may just have a little asterisk at the end of it.

Even insurance companies are getting more involved in preventing narcotic addiction and or diversion.

Below is part of a letter I received from Blue Cross regarding a patient who had received narcotic pain medications from more than three different physicians.

Don’t know if the insurance companies will impose any consequences on patients who exhibit what insurance companies consider to be “drug seeking” behavior, but  keep in mind that you are being watched when you fill those prescriptions for controlled substances. States like Tennessee may just put you behind bars for trying to game the system, too.


  1. I’m curious here, as I was given an invitation to assist in one of these programs.

    In terms of commercial insurance, employer, union etc, consequences are unlikely. As it stands now, there is a firm consensus that if they have a responsibility, it’s to let the prescribers know.

    In Medicaid, it’s a bit of a different story. Depending on the region, Medicaid narcotic fraud and doctor shopping is just mindboggling. A lot of our Medicaid plans have updated their DUR to refuse to cover concurrent short acting opioids. At least two plans I know of, both Medicaid, have gone so far as to lock members into a single pharmacy, requiring them to get all their medications filled at one place if they display recurrent claims at different pharmacies and different doctors over a 6m-12m period.

    As a prescriber, do you find this sort of thing useful? Or should it be left to state databases and point of sale pharmacies to handle this sort of intervention?

    • The more information I have, the better I can make an informed decision. There are many problems with the current program in my state. I get no REAL TIME information. The databases aren’t updated frequently and the information is bad. In addition, I live near a state border, so patients can go to ER’s on both sides of the border and I have no access to information from the other state.

      I think locking patients into a pharmacy is a good idea. It helps to get a better handle on things. But I can think of many ways to skirt that too. First they can use multiple aliases Second, if their intent is to sell the drugs, they can go to a different pharmacy, pay cash, then still sell them on the street. Last, they frequently come in on nights/weekends when the pharmacy isn’t open (and I can’t call to find out their prescribing history.).

      • That is a significant problem with databases, but it’s also variable from state to state. Most require at best, weekly uploads of controlled substance scripts, few are more frequent. Many are monthly or even worse. I know at least one state where the database is updated weekly, but the state database is incompatible with electronic pharmacy standards, and corrupts data as it’s uploaded.

        The Lock In has been moderately successful, but it’s still a work in progress. As I’m familiar with it, it takes the form of overriding the plan’s pharmacy network for a particular member. Any claims from a pharmacy other than the locked in one are rejected with a message saying the member can only use a particular pharmacy, and a phone number to call for possible overrides. While a member can still pay cash, that’s reported to the state database. One of the criteria for letting someone out of the program is no cash-paid prescriptions in the state database.

        It obviously has limitations, but it works quite well when properly applied. In Medicaid many patients are unwilling (and frequently unable) to pay cash. Combined with other programs, it makes a good deal of difference in a state that deals with ~$40-$100 million in narcotic fraud and diversion in a year.

  2. How do they distinguish between legit claims with unlucky people (this year I’ve broken my knee and had two root canals, so that’s 3 ‘controlled substance’ Rx from three separate doctors in 6-12 months)?

    • The first step is that claims are filtered through Drug Utilization Review software. This is the same software the PBM uses to identify drug interactions and precautions.

      Speaking from experience, three prescriptions in a year is nothing. We pretty regularly come across 2-5 a month, ongoing for quite some time. For this kind of intervention, they’re usually looking for regular prescriptions, from multiple providers (pharmacy and MD), typically for differing strengths and quantities and prescriptions that overlap.

      When pharmacies bill medication, they also indicate the number of days a prescription should last according to the directions (eg, 40 Hydrocodone/APAP 5-500 for 10 days). If then, after 5 days a prescription for a 10-325 strength is billed, that would indicate an overlap.

      The data from the software is compiled, typically by Pharm. Techs (who develop quite a knack for identifying problems) and then handed to a clinician of some sort. In most cases, this is going to be a Pharm.D. The pharmacist then uses their judgement based on the data they have to decide wether some attempt at intervention, or MD notification is warranted.

    • I agree, three Rx’s in a year is not enough to cause suspicion unless there are other incriminating factors.

  3. Even though I am not obligated to do so, my monthly long acting opiod (ortho issues that date back to my Army days) is written by the exact same doc and filled at the exact same pharmacy. I am quite fond of having “RN” after my name and do not want to do anything that even HINTS of the possibility of abuse or diversion. My doc is happy, my insurance company is fine, and I get to continue to work for a living rather than making SSDI my life’s goal.

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