“Are you in pain?”
Millions of Facebook users saw an ad asking this question and suggesting that relief was available by clicking here. Those who clicked were presented with a pop-up survey that sought more information about their pain condition, along with insurance and personal contact information. For the unsuspecting folks who filled out the survey, their involvement in a multimillion-dollar fraudulent prescription drug scheme had just begun.
I head a team of investigators at Express Scripts. We spend each day identifying and tracking social media scams that target vulnerable individuals looking for relief from pain and other ailments. Facebook and other social media platforms are the latest breeding ground for prescription drug fraud perpetrated by physicians and pharmacies who’ve been recruited by third-party “marketing firms” posing as telemedicine companies to sell high-cost medications at extra-inflated prices to consumers’ health insurance plans.
The scheme often works like this: Once you’ve given your phone number, you get a call from the marketing firm. A representative asks questions about your condition and your health insurance provider. Most states have a patient counseling prerequisite that requires a patient to have a consultation with the clinician prescribing a medication and/or the pharmacist filling it. Sometimes this conversation, or a perfunctory telemedicine call with a health care provider, is claimed to fulfill the patient counseling requirement.
With little or no understanding of your medical history or condition, a physician who is in on the scam writes a prescription for an expensive pain drug, typically a topical application such as lidocaine cream, that is usually available over the counter at a fraction of the cost. The prescription is sent to a specific mail order pharmacy that is also involved in the scam. Some days later, you receive the medication at your doorstep. Most often the copay has been waived, and the insurer is left to pay the bill for the medication.
Medicare used to be the primary target of this type of fraud. But as the government aggressively pursued these schemes, the perpetrators shifted their sights to consumers with commercial insurance. The schemes take advantage of widely varying state laws governing pharmacy and telemedicine practices. They can blur both legality and law enforcement jurisdictions when prescriptions are sent across state lines through mail order pharmacies. Telemedicine, which provides some people with much-needed access to health care practitioners, has been harnessed for these prescription drug scams and contributes to their proliferation.
In some cases, the scammers prey specifically on people with insurance plans that do not allow the insurer to restrict the prescription of specific medications. Such restrictions are often absent in plans that allow a more generous benefit, such as union-provided plans.
In one case that our team investigated, a physician in the Dallas area wrote almost 3,000 suspect prescriptions for patients, almost all of them during a nine-month period, costing more than $4 million. To put this into perspective, the average cost for each of these prescription claims was around $1,400, whereas many of these medications could be purchased over the counter or as a prescription for less than $50 each.
Using advanced data analytics that compared prescribing patterns of specialists in the physician’s area, we were able to identify his prescribing behaviors as potentially fraudulent and reported him to the FBI for investigation. Once aware that he was under scrutiny, the physician ceased writing all prescriptions for these high-cost drugs.
Yet the scam continued. Another Dallas-area doctor, likely recruited by the same “marketing firm,” began writing an excessive number of high-cost prescriptions for the same patients as the doctor originally involved in the fraud. In a four-month period, he wrote more than 1,000 prescriptions for drugs that cost a total of $1.75 million. Our investigative team followed the prescription trail to this second physician, who we also reported to the FBI.
So far this year, we have referred 12 prescribers to 18 separate state medical boards who racked up more than $17 million in prescriptions. We have also shared information with the FBI about an additional eight prescribers with a combined drug spend of almost $14 million. And this is just the tip of the iceberg.
Leveraging big data to identify the perpetrators of prescription drug scams has been an essential tool in ferreting out these fraudulent players.
An even better way to halt these scams is for consumers to never click on beguiling ads in the first place — and, if they do, to never give out personal or insurance information when asked for it online. Also be wary of anyone offering free medication on social media or rewards such as gift cards for filling a prescription. And as we enter an age when telemedicine is becoming a more common form of care, it’s especially important to make sure that the clinician on the other end of the line is trustworthy.
If you’re solicited by a physician on social media, assume he or she is more interested in money than in your health.
Rick Battelle is the director of the fraud, waste, and abuse program at Express Scripts.