Prescription abuse

Hunter1

Based on reports which I receive from our PBM, I believe we have an employee/family which is abusing prescription pain relievers. Both employee and spouse receive a narcotic pain reliever each month (has been going on for over a year), and the spouse fills two prescriptions for the same drug each month, prescribed by two doctors and filled at two pharmacies. Now, my problem: Neither my PBM nor my TPA will do anything about this situation, even though the pharmacist at the PBM says that this 'appears to be an abuse situation'. How's that for understatement???

How have you handled a similar situation? Does your PBM get involved? Any advice?

Don D

I'll defer to Rush Limbaugh.

SMace

I do not receive employee specific data from my PBM and do not really want that info for this very reason. I would rely on my drug policy to take care of my employee and leave it alone.

mushroomHR

About two years ago someone was having prescription pain killers filled at various pharmacies under my health insurance. It was a person who has the same name as mine and they were getting these prescriptions filled every two weeks. I reported this to my health care carrier, the pharmacies, and any other agency I could think of. No one seemed to care and fortunately it finally stopped.

Six months later it happened again. This time I filed police reports and reported it again to my health care carrier. Again, they didn't care. It evidently wasn't a big enough case for them to pursue and I have heard nothing since.

My advice to you is since you reported it once, that is your only obligation. Let the PBM and TPA handle it if they want to. I was totally frustrated with my situation because I knew it was abuse and everyone said this person was abusing the medication but no one wanted to take any action. Sorry I don't have any better advice but good luck.

Hunter1

Don: Thanks for the help! : )

SMace: This is exactly the 'head-in-the-sand' approach I don't want to take. I have concerns for my employee's safety and that of their family and the rest of the community. We had another employer in the community that had a similar problem and the individual abusing the drug ended up being killed in an auto accident. In addition, so far, this has cost our plan about $35,000 (street value over $250,000). I am of the opinion that it is the family member who is abusing the drug, so our drug testing will never catch the problem. I don't feel that I'm acting in the best interests of the plan (fiduciary duties) or my employee to just ignore the situation, but I'm not getting any assistance.

SMace

I think you've fulfilled your fiduciary duty by notifying your TPA and PBM. It's not illegal to be addicted to lawfully prescribed drugs. You say "head-in-the-sand" and I say sound business decision. I question the legality of you even getting this info. Do all your employees know that you are privy to their prescription drug use?

But, since you want advice on how to do something about this, call the two doctors and alert them of the dual prescriptions. Be prepared to explain how you came across the info, just in case.

Shadowfax

Smace: I think your first response was right on - don't need this kind of info because..what can you do with it? I would NOT call the doctor, not ever. There are few enough reasons for the emp/er to go directly to the ees Dr. and I don't think this is one of them. Sorry to say, Hunter has some info it is probably best to ignore, as if you really didn't have it. Maybe the carrier, or 3rd party admin can raise it, but I don't think the emp/er should be raising it.

Whatever

Change PBM and TPA. We had a similar situation and it was caught immediately by the insurance carrier. Of course, the PBM and TPA don't care. They are just going to pass along the cost.

pork1

HUNTER1: Welcome to the HR world of delimas. My advise is to contact your retained attorney and get their opinion. OSHA demands that you provide a safe working environment! What is your defense, regardless of how you came about the information, your testimony is "I DO NOT KNOW OR I HAVE NO INFORMATION" is not where you want to be when the employee standing next to the drugged employee gets hurt or worse 'Killed'. I have found when we HRs get information we are obligated to do something positive with the information. Now considerating my view, how do you engineer a safe working environment, "do nothing" and you are wrong, "do a little" and someone is hurt you are wrong again. You have no choice but to take positive action, which may be as little as discussing the situation with retained legal authority and then rest comfortably each night knowing you did the right thing.

PORK

marc

With all of the hoopla made by various law enforcement agencies, the medical profession and others about the dangers of abusing any sort of drug, especially pain killers, it is amazing to me that no one will do anything about this. Shouldn't the insurance company have contact that verifies with both doctors in such a manner that each knows about the other?

I guess you have to be a celebrity before anyone really gets excited about these things.

dchr9203

I am assuming that because you have access to this information, you are self- or partially self-funded. As such, you have "control" of your plan and have rights under that control, which includes case and risk management, and in some cases, suspending benefits. Best thing is to contact your attorney for guidance. Once you've done that, and with their guidance, you have the right to notify the employee of your findings, possibly suspending benefits, and reporting to authorities.

zen

Tread carefully when considering reporting this situation. What does your corporate attorney have to say about possible HIPPA violations? If your primary concern is that an employee may create an unsafe work environment due to abuse of prescription drugs, I would suggest documentation of any performance problems following your disciplinary program and drug testing for cause then referral to an EAP.

My questions to you regarding disclosure of employee prescription use:
Would you report the use and frequency of any other medications - such as antidepressants, antibiotics, antipsychotics, or the continued use of birth control pills by a married woman who's husband had his vasectomy paid for by your insurance carrier? Do you want to go down this path with your employees?

Hunter1

Whatever kind of hit the nail on the head by saying that the PBM and TPA don't care, they just pass along the cost. Since we are self-funded, we are the insurance company. If we paid premiums to a carrier, does anyone think the carrrier would just allow this situation to continue at a cost of $30,000+ per year?

To repeat, I don't think it is the employee who is using the stuff, I believe it's the spouse.

No, I don't want to go down that path with my employees, and the ONLY reason this caught my attention at all is that this family is having three prescriptions filled per month (actually a lot more than that, but just for this one drug), at a little over $1000/script for two of them, $480/script for the other one. Those kind of numbers jump off the page in a small group like ours.

We have a great in-house attorney, but she could study HIPAA and related regulations for the next three weeks and not know as much about it as many well-versed Forumites. That's why I requested your help.

pork1

HUNTER1: Please fo not also forget in our self-funded medical plans the $30,000.00 spent for abusive activities is also $30,000.00 spent and paid for by all other paid members of the plan. We try our best to cut down on cost, but all to often we fail to control the abuse of the system which cost all plan members.

We have this year put into our plan a $100.00 cost for each ER use for routine medical care, plus the ER charges for their facilities use. We did this because there was way to much ER use for "runny noses" for pppp by the parents of our plan. We have also added an administrative cost for the processing of claims cause by vehicle accidents, where a seat belt was not used. In our state "buckling-up is the law". It is wrong for all plan participants to share in the stupidity of the general plan population. These two items plus a $100.00 increase in participant deductablies helped us to keep our plan premium cost for our employees the same as the past three years. Those that do not get sick or abuse the system are not the one's paying for the self funded medical plan. They pay the premium to be enrolled just incase the medical plan is needed for their individual or family welfare.

Do what is right for the whole plan, based on legal guidance.

PORK

SMace

One more point. You pay your TPA to care. They should do what you tell them. If I told my TPA to do something resonable (which is what you are doing) and they told me no, I'd go through the roof. I would tell them in no uncertain terms that they either do what you say or you will have a new TPA next year.

If you want even more leverage, call your broker and tell him/her that your going to drop them if they don't help you.

I stand by my advice not to pursue it unless your TPA or PBM take it on.

Whatever

Our plan has certain safeguards--i.e. most prescriptions can only be filled once a month, some prescriptions require prior approval. And, of course, if you don't want to go the medication on the formulary, you will pay a lot more for it.