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United States Government Accountability Office: 
GAO: 

Report to Congressional Requesters: 

September 2011: 

Medicare Part D: 

Instances of Questionable Access to Prescription Drugs: 

GAO-11-699: 

GAO Highlights: 

Highlights of GAO-11-699, a report to congressional requesters. 

Why GAO Did This Study: 

In 2009, GAO reported on doctor shopping in Medicaid, where 
individuals see several doctors and pharmacies, receiving more of a 
drug than was intended by any single physician. Questions have been 
raised about whether similar activity exists in Medicare Part D.
GAO was asked to (1) determine the extent to which Medicare 
beneficiaries obtained frequently abused drugs from multiple 
prescribers, (2) identify examples of doctor shopping activity, and 
(3) determine the actions taken by the Centers for Medicaid & Medicare 
Services (CMS) to limit access to drugs for known abusers. To meet the 
objectives, GAO analyzed Medicare Part D claims for calendar year 2008 
to identify potential doctor shoppers. To identify examples, GAO chose 
a nonrepresentative selection of 10 beneficiaries based on a number of 
factors, including the number of prescribers. GAO also interviewed 
policy officials from CMS and from prescription drug plans that 
administer the drug benefit program. 

What GAO Found: 

GAO found indications of doctor shopping in the Medicare Part D 
program for 14 categories of frequently abused prescription drugs. 
About 170,000 beneficiaries (about 1.8 percent of beneficiaries 
receiving these 14 categories of drugs) acquired the same class of 
frequently abused drugs, primarily hydrocodone and oxycodone, from 
five or more medical practitioners during calendar year 2008 at a cost 
of about $148 million (about 5 percent of the total cost for these 
drugs). About 120,000 of these beneficiaries were eligible for 
Medicare Part D because of a disability. There may be justifiable 
reasons for receiving prescriptions from multiple medical 
practitioners, such as visiting specialists or several prescribers in 
the same medical group. However, one individual received prescriptions 
from 87 different medical practitioners in 2008. In such situations, 
there is heightened concern that Medicare beneficiaries are seeing 
several medical practitioners to support and disguise an addiction. 

GAO judgmentally selected 10 beneficiaries and found that they were 
doctor shopping for prescription drugs. These cases are among the more 
egregious and cannot be generalized beyond the examples presented. 

Table: Examples of Doctor Shopping Activity: 

State: Georgia;  
Type of drug: Oxycodone 
Details: 
* Beneficiary received prescriptions in 2008 for 3,655 oxycodone pills 
(a 1,679-day supply) written by 58 different prescribers; 
* Two pharmacies later refused to fill prescriptions for the 
beneficiary because of suspicions of forgery. 

State: California;  
Type of drug: Fentanyl 
Details: 
* Beneficiary received prescriptions in 2008 for 1,758 days worth of 
fentanyl written by 21 different prescribers; 
* Beneficiary’s physician received a letter from the state of 
California stating that within a 4-month period the beneficiary had 
received 33 prescriptions for controlled substances from 10 different 
prescribers. 

State: Texas; 
Type of drug: Hydrocodone 
Details: 
* Beneficiary received prescriptions in 2008 for 4,574 hydrocodone 
pills (a 994 days supply) written by 25 different prescribers; 
* One of the beneficiary’s physicians stated it is dangerous to be 
consuming the amount of narcotics being prescribed. 

Source: GAO. 

[End of table] 

CMS has systems in place to identify individuals with doctor shopping 
behavior; however, according to CMS policy officials, federal law may 
not authorize them to restrict these individuals’ access to drugs, 
including highly abused drugs, such as hydrocodone and oxycodone. One 
option to control doctor shopping used by Medicaid and some private 
sector plans is the restricted recipient program. It limits 
individuals identified as doctor shoppers to one prescriber, one 
pharmacy, or both for receiving prescriptions. There are issues to 
consider with a restricted recipient program, such as potentially 
denying legitimate drug needs and unknown administrative costs. These 
issues should be balanced against the potential protections such a 
program can provide. Doctor shopping for frequently abused drugs can 
increase the cost of the Part D program and jeopardize patient care. 
Controls proven to reduce doctor shopping could be considered by CMS. 

What GAO Recommends: 

GAO recommends that CMS review its findings and consider steps such as 
a restricted recipient program for identified doctor shoppers and seek 
congressional authority, as appropriate. CMS agreed with the overall 
recommendation to improve its efforts to curb overutilization in Part 
D, but disagreed that a restricted recipient program is necessarily 
the appropriate control for the Part D program. 

View [hyperlink, http://www.gao.gov/products/GAO-11-699]. For more 
information, contact Gregory Kutz at (202) 512-6722 or kutzg@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

Some Medicare Beneficiaries Received Prescriptions from Five or More 
Medical Practitioners to Obtain the Same Class of Frequently Abused 
Drugs: 

Examples of Doctor Shopping in Medicare Part D: 

Systems Are in Place to Identify Inappropriate Drug Use, but Measures 
to Stop the Activity Are Limited: 

Conclusion: 

Recommendation for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Comments from the Centers for Medicare & Medicaid Services: 

Appendix II: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Fourteen Frequently Abused Prescription Drug Classes: 

Table 2: Number of Beneficiaries Who Received 1 of 14 Prescription 
Drug Classes from Five or More Prescribers in 2008: 

Table 3: Examples of Doctor Shopping of Prescription Drugs in Medicare 
Part D: 

Figure: 

Figure 1: States with Operational Prescription Drug Monitoring 
Programs as of February 2011: 

Abbreviations: 

CMS: Centers for Medicare & Medicaid Services: 

CSA: Controlled Substances Act of 1970: 

DEA: Drug Enforcement Administration: 

DOJ: Department of Justice: 

DUR: drug utilization review: 

HHS: Department of Health and Human Services: 

LICS: Low-Income Cost-Sharing Subsidy: 

MEDIC: Medicare Drug Integrity Contactor: 

MMA: Medicare Prescription Drug, Improvement, and Modernization Act of 
2003: 

NPI: National Provider Identifier: 

PDMP: prescription drug monitoring program: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

September 6, 2011: 

The Honorable Thomas R. Carper:
Chairman:
The Honorable Scott P. Brown:
Ranking Member:
Subcommittee on Federal Financial Management, Government Information, 
Federal Services, and International Security:
Committee on Homeland Security and Governmental Affairs:
United States Senate: 

The Honorable John McCain:
United States Senate: 

Prescription drug abuse is a serious and growing public health 
problem. According to the Centers for Disease Control and Prevention, 
drug overdoses, including those from prescription drugs, are the 
second leading cause of deaths from unintentional injuries in the 
United States, exceeded only by motor vehicle fatalities. Unlike 
addiction to heroin and other drugs that have no accepted medical use, 
addiction to some controlled substances can be unknowingly financed by 
insurance companies and public programs, such as Medicare. There are 
reports and allegations that criminals and drug abusers are able to 
illegitimately acquire controlled substances by filing fraudulent 
claims, seeking treatment from medical practitioners for feigned 
injuries and illnesses, and perpetrating other fraudulent activities. 
The financial cost associated with controlled substance fraud and 
abuse is more than the cost of drug purchases since there are related 
medical services, such as doctor and emergency room visits, that 
precede the dispensing of these medications. 

GAO reported, in September 2009, on an investigation of Medicaid fraud 
and abuse related to controlled substances in selected states. 
[Footnote 1] The investigation found about 65,000 Medicaid 
beneficiaries and providers involved in potential fraudulent or 
abusive purchases of controlled substances in five selected states. 
These Medicaid beneficiaries in the five selected states acquired the 
same class of controlled substance from six or more different medical 
practitioners during fiscal years 2006 and 2007. Such activities, 
known as doctor shopping, resulted in about $63 million in Medicaid 
payments. According to the Drug Enforcement Administration (DEA), 
doctor shopping generally refers to visits by an individual to several 
doctors, each of whom writes a prescription for a controlled 
substance. The individual will visit several pharmacies, receiving 
more of the drug than intended by any single physician, typically for 
the purpose of abuse.[Footnote 2] Based on the findings from the 
Medicaid investigation, you expressed concern about whether similar 
doctor shopping was taking place in the Medicare Part D program. 

Medicare Part D provides voluntary, outpatient prescription drug 
coverage for eligible individuals 65 years and older and eligible 
individuals with disabilities. The Medicare Part D program, which 
began in January 2006, is administered by the Department of Health and 
Human Services' (HHS) Centers for Medicare & Medicaid Services (CMS). 
CMS contracts with private companies--such as health insurance 
companies and pharmacy benefit managers--to serve as Medicare Part D 
prescription drug plans. Over 27 million individuals were enrolled in 
Medicare Part D in 2010 and benefit expenditures were about $53 
billion.[Footnote 3] Because of Medicare's vulnerability to fraud, 
waste, and abuse, GAO has designated Medicare as a high-risk program. 
[Footnote 4] We and HHS's Inspector General have previously reported 
that the size, nature, and complexity of the Medicare Part D program 
make it particularly at risk for fraud, waste, and abuse.[Footnote 5] 
You asked us to (1) determine the extent to which Medicare 
beneficiaries obtained frequently abused drugs from multiple medical 
prescribers, (2) identify examples of doctor shopping activity, and 
(3) determine the actions taken by CMS to limit access to prescription 
drugs for known abusers. 

To determine the extent to which Medicare beneficiaries obtained 
frequently abused drugs through the prescriptions of multiple medical 
prescribers, we extracted the claims for the 14 selected classes of 
drugs from the approximately 1 billion Medicare Part D paid claims for 
calendar year 2008. From this subset of claims we determined the 
number of beneficiaries who saw at least five different medical 
practitioners for the same class of drugs. We selected the 14 classes 
of drugs, 12 of which are controlled substances, and the five or more 
prescribers threshold based on our review of drug diversion literature 
and prior GAO work and discussions with a criminal investigator whose 
recognized expertise is in drug diversion and with an official 
representing state prescription drug monitoring programs. To determine 
the total number of different prescribers from which a beneficiary 
received a prescription, we identified and totaled the number of 
different prescribers shown in each beneficiary's claims data by each 
class of drug.[Footnote 6] Some duplication may have occurred in our 
estimate of doctor shoppers because the Medicare Part D prescription 
claims identify prescribers using either their own identifier or a 
group practice identifier. However, our analysis showed that the 
extent of claims with group level identifiers was insignificant. 
[Footnote 7] 

To identify examples of doctor shopping activity, we selected 
beneficiaries from those identified as seeing at least five different 
medical practitioners for the same class of drugs from a 
nonrepresentative selection of five states: California, Georgia, 
Maryland, Massachusetts, and Texas. These states were selected based 
on geographical location and to provide a mixture of states that did 
and did not have programs for monitoring prescriptions for controlled 
substances.[Footnote 8] We further narrowed the number of individuals 
for our investigation primarily based on data showing a high number of 
prescriptions filled within the 14 classes of drugs, a high number of 
different prescribers involved, and the overlap of prescriptions. To 
further develop these examples, we identified overlapping 
prescriptions for the same class of drug from different prescribers, 
and interviewed selected employees from pharmacies and medical 
practitioners to confirm that these individuals were doctor shopping. 
Although our 10 case studies allowed us to identify issues related to 
the doctor shopping of Medicare Part D drugs, circumstances of each 
case are unique and cannot be generalized. 

To determine the actions taken by CMS to limit access to prescription 
drugs for known abusers, we obtained and reviewed agency documents, 
including CMS regulations and program integrity requirements related 
to Medicare Part D. We also interviewed policy officials from CMS, 
CMS's fraud contractor, and three Medicare Part D contractors. We 
selected the Medicare Part D contractors based primarily on the number 
of beneficiaries enrolled in their plans whom we identified as 
potential doctor shoppers for these 14 classes of highly abusive 
drugs. These interviews included a review of the various controls 
either in place or available for use by prescription drug plans, along 
with their benefits and implementation issues. 

To determine the reliability of the Medicare claims data, we reviewed 
related documentation and performed electronic testing to determine 
the validity of specific data elements in the databases that we used 
to perform our work.[Footnote 9] Based on the results of this work, we 
concluded that the data elements used for this report were 
sufficiently reliable for our purposes. 

We conducted this forensic audit from May 2010 to May 2011 in 
accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe 
that the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our audit objectives. We conducted 
our related investigative work in accordance with standards prescribed 
by the Council of the Inspectors General on Integrity and Efficiency. 

Background: 

Medicare Part D Provides Prescription Drug Benefits: 

The Medicare Part D program, administered by CMS, provides a 
voluntary, outpatient prescription drug benefit for eligible 
individuals 65 years and older and eligible individuals with 
disabilities. Beneficiaries may pay for part of the drug benefit 
through monthly premiums, deductibles, and co-pays. Low-income 
beneficiaries can receive substantial premium and cost sharing 
assistance. CMS data indicate that about 19 percent of the individuals 
who received Medicare Part D benefits in 2008 were eligible because of 
their disabilities. CMS contracts with private companies--such as 
health insurance companies and companies that manage pharmacy 
benefits--to provide Part D prescription drug benefit plans for 
Medicare beneficiaries. These companies are referred to as Part D plan 
sponsors. 

The Medicare Prescription Drug, Improvement, and Modernization Act of 
2003 (MMA), which established the Part D program, requires all Part D 
plan sponsors to have programs to safeguard Part D from fraud, waste, 
and abuse. CMS regulations establish the requirements for 
comprehensive compliance plans for Part D plan sponsors. To guide 
Medicare Part D plan sponsors in designing a fraud and abuse program 
that addressed Medicare Part D risks, in April 2006 CMS issued 
recommendations for Medicare Part D plan sponsors' fraud and abuse 
programs based on input from various sources, including law 
enforcement and industry representatives. The guidance, issued as 
chapter 9 in the Prescription Drug Benefit Manual, contains further 
interpretation and guidelines on the steps sponsors should take to 
detect, correct, and prevent fraud, waste, and abuse in Part D. In the 
chapter 9 guidance, CMS identifies examples of potential fraud, waste, 
and abuse by Medicare beneficiaries, such as beneficiaries engaging in 
doctor shopping, where a patient seeks prescriptions from multiple 
physicians with the intent to abuse or sell drugs, and directs the 
Part D plan sponsors to report potential cases to the Medicare Drug 
Integrity Contactor (MEDIC). The MEDIC contracts with CMS to support 
audit, oversight, and antifraud and abuse efforts in Part D. 

Controlled Substances Act Classifies Drugs Based on Their Potential 
for Abuse and Dependence: 

The Controlled Substances Act of 1970 (CSA)[Footnote 10] established a 
classification structure for certain drugs and chemicals used in drug 
manufacturing. Controlled substances are classified into five 
schedules on the basis of their currently accepted medical use and 
potential for abuse and dependence. Schedule I drugs--including 
heroin, marijuana, and hallucinogens such as LSD--have a high 
potential for abuse, no currently accepted medical use in treatment in 
the United States, and a lack of accepted safety for use under medical 
supervision. Schedule II drugs--including methylphenidate (Ritalin) 
and opiates such as hydrocodone, morphine, and oxycodone--have a high 
potential for abuse and may lead to severe physical or psychological 
dependence but have a currently accepted medical use. Drugs on 
Schedules III through V have medical uses and successively lower 
potentials for abuse and dependence. Schedule III drugs include 
anabolic steroids, some preparations of codeine, hydrocodone in 
combination with aspirin or acetaminophen, and some barbiturates. 
Schedule IV contains such drugs as the antianxiety medications 
diazepam (Valium) and alprazolam (Xanax). Schedule V includes 
preparations such as cough syrups with codeine. All drugs but those in 
Schedule I are legally available to the public with a prescription. 

CSA mandates that DEA establish a closed system of control for 
manufacturing, distribution, and dispensing of controlled substances. 
Specifically, any person who manufactures, dispenses, imports, 
exports, or conducts research with controlled substances must register 
with DEA (unless exempt), keep track of all stocks of controlled 
substances, and maintain records to account for all controlled 
substances received, distributed, or otherwise disposed of. Although 
all registrants, including pharmacies, are required to maintain 
records of controlled substance transactions, only manufacturers, 
distributors, and pharmacies authorized to dispense controlled 
substances by means of the Internet are required to report certain 
controlled substance transactions,[Footnote 11] including sales to the 
retail level, to DEA. The data provided to DEA are available for use 
in investigations of illegal diversions at the manufacturer and 
distributor levels. The act does not require pharmacies to report 
information on dispensing to the patient level to DEA.[Footnote 12] 

Prescription Drug Monitoring Programs Have Been Implemented by Most 
States: 

Most states have implemented prescription drug monitoring programs 
(PDMP). These programs can help prevent and detect the diversion and 
abuse of pharmaceutical controlled substances, particularly at the 
retail level. States that have implemented PDMPs have the capability 
to collect and analyze data on filled and paid prescriptions, 
including those from the Medicare Part D program, more efficiently 
than those without such programs, where the collection of prescription 
information can require a time-consuming manual review of pharmacy 
files. If used properly, PDMPs can detect diversion of the drugs by 
health care prescribers, pharmacies, and patients. We have reported 
that states with PDMPs have realized benefits in their efforts to 
reduce drug diversion.[Footnote 13] 

Figure 1 shows that a total of 34 states had operational PDMPs as of 
February 2011. These states vary in the extent to which schedules of 
controlled substances are monitored. Some states also monitor certain 
noncontrolled substances. According to the Department of Justice 
(DOJ), in states that have implemented PDMPs, doctor shopping has 
decreased. However, since determined doctor shoppers can travel to 
nearby states to bypass a PDMP, DOJ has also reported an increased 
need for information sharing between neighboring states to facilitate 
the interstate exchange of PDMP data.[Footnote 14] 

Figure 1: States with Operational Prescription Drug Monitoring 
Programs as of February 2011: 

[Refer to PDF for image: illustrated U.S. map] 

States with Operational PDMPs: 

Alabama: 
Arizona: 
California: 
Colorado: 
Connecticut: 
Hawaii: 
Idaho: 
Illinois: 
Indiana: 
Iowa: 
Kentucky: 
Louisiana: 
Maine: 
Massachusetts: 
Michigan: 
Minnesota: 
Mississippi: 
Nevada: 
New Mexico: 
New York: 
North Carolina: 
North Dakota: 
Ohio: 
Oklahoma: 
Pennsylvania: 
Rhode Island: 
South Carolina: 
Tennessee: 
Texas: 
Utah: 
Vermont: 
Virginia: 
West Virginia: 
Wyoming: 

States without Operational PDMPs: 
Alaska: 
Arkansas: 
Delaware: 
District of Columbia: 
Florida: 
Georgia: 
Kansas: 
Maryland: 
Missouri: 
Montana: 
Nebraska: 
New Hampshire: 
New Jersey: 
Oregon: 
South Dakota: 
Washington: 
Wisconsin: 

Sources: GAO; Alliance of States with Prescription Monitoring Programs 
(data). 

[End of figure] 

Some Medicare Beneficiaries Received Prescriptions from Five or More 
Medical Practitioners to Obtain the Same Class of Frequently Abused 
Drugs: 

Our analysis of Medicare Part D claims found that 170,000 Medicare 
beneficiaries received prescriptions from five or more medical 
practitioners for the 12 classes of frequently abused controlled 
substances and 2 classes of frequently abused noncontrolled substances 
in calendar year 2008. This represented about 1.8 percent of the 
Medicare Part D beneficiaries who received prescriptions for these 14 
classes of drugs during the same calendar year. These individuals 
incurred approximately $148 million in prescription drug costs 
[Footnote 15] for these drugs,[Footnote 16] much of which is paid by 
the Medicare program. Our analysis also found the following: 

* Most of these 170,000 Medicare beneficiaries who were prescribed 
prescriptions from five or more practitioners were eligible for 
Medicare Part D benefits based on a disability. Specifically, 
approximately 120,000 Medicare beneficiaries (about 71 percent) were 
eligible for Medicare Part D benefits based on a disability. 

* Of these 170,000 beneficiaries, approximately 122,000 beneficiaries 
(72 percent) received a Medicare Low-Income Cost-Sharing (LICS) 
subsidy.[Footnote 17] 

* Of the 14 classes of frequently abused drugs analyzed, hydrocodone 
and oxycodone were the most prevalent. These drugs represented over 80 
percent of the instances of potential doctor shopping we identified. 

In some cases, beneficiaries may have a justifiable reason for 
receiving prescriptions from multiple medical practitioners, such as 
visiting specialists or several prescribers in the same medical group. 
However, our analysis of Medicare Part D claims found that about 600 
Medicare beneficiaries received prescriptions from 21 to 87 medical 
practitioners in the same year. In these situations, there is 
heightened concern that these Medicare beneficiaries may be seeking 
several medical practitioners to support and disguise an addiction. 
[Footnote 18] According to DEA, drug abusers use diversion techniques 
such as doctor shopping to acquire controlled prescription drugs. 
Further, DEA has also stated that diverted controlled prescription 
drugs have been added to the supplies of some illicit drug 
distributors.[Footnote 19] For example, according to DOJ, in 2008 
hydrocodone tablets and oxycodone tablets were illicitly sold in 
California, one of the five states we selected for more detailed case 
investigations, for $5 and $80 per tablet, respectively.[Footnote 20] 

Our analysis of Medicare Part D claims did not focus on all 
prescription drugs, but instead targeted 12 classes of frequently 
abused controlled substances and 2 classes of frequently abused 
noncontrolled substances, as shown in table 1. Our analysis does have 
certain limitations based on the data. Specifically, the data 
submitted to CMS did not identify the prescriber for many Part D 
claims because of blank or invalid prescriber identification values. 
At least 5.8 percent of the prescription claims for these 14 
categories of drugs contained blank or invalid prescriber 
identification values. These claims were not included in our analysis. 
Therefore, we potentially understated the total number of unique 
prescribers for each beneficiary who received a prescription for all 
the claims paid. 

Table 1: Fourteen Frequently Abused Prescription Drug Classes: 

Prescription drug classes: Amphetamine derivatives; 
Other names: Adderall; 
DEA schedule[A]: II; 
Description: Non-narcotic stimulant. 

Prescription drug classes: Benzodiazepines[B] (e.g., Diazepam, 
Alprazolam, Lorazepam, Clonazepam, Temazepam, and Triazolam); 
Other names: Valium, Xanax, Klonopin, Ativan, Restoril, and Halcion; 
DEA schedule[A]: IV; 
Description: Non-narcotic depressant. 

Prescription drug classes: Carisoprodol; 
Other names: Soma; 
DEA schedule[A]: Not scheduled; 
Description: Muscle relaxant. 

Prescription drug classes: Codeine with Acetaminophen; 
Other names: Tylenol with Codeine; 
DEA schedule[A]: III; 
Description: Narcotic painkiller. 

Prescription drug classes: Fentanyl; 
Other names: Duragesic and Actiq; 
DEA schedule[A]: II; 
Description: Narcotic painkiller. 

Prescription drug classes: Hydrocodone combinations; 
Other names: Lorcet, Lortab, Norco, and Vicodin; 
DEA schedule[A]: III; 
Description: Narcotic painkiller. 

Prescription drug classes: Hydromorphone; 
Other names: Dilaudid; 
DEA schedule[A]: II; 
Description: Narcotic painkiller. 

Prescription drug classes: Meperidine; 
Other names: Demerol; 
DEA schedule[A]: II; 
Description: Narcotic painkiller. 

Prescription drug classes: Methadone[C]; 
Other names: Methadose and Dolophine; 
DEA schedule[A]: II; 
Description: Narcotic painkiller. 

Prescription drug classes: Methylphenidate; 
Other names: Ritalin, Concerta, and Methylin; 
DEA schedule[A]: II; 
Description: Non-narcotic stimulant. 

Prescription drug classes: Morphine; 
Other names: MS Contin, Roxanol, Avinza, and Kadian; 
DEA schedule[A]: II; 
Description: Narcotic painkiller. 

Prescription drug classes: Non-Benzodiazepine sleep aids (e.g., 
Zolpidem, Zopiclone, and Zaleplon); 
Other names: Ambien, Sonata, and Lunesta; 
DEA schedule[A]: IV; 
Description: Non-narcotic sedative. 

Prescription drug classes: Oxycodone; 
Other names: OxyContin, Roxicodone, Percocet, Endocet, and Roxicet; 
DEA schedule[A]: II; 
Description: Narcotic painkiller. 

Prescription drug classes: Tramadol; 
Other names: Ultram and Ultracet; 
DEA schedule[A]: Not scheduled; 
Description: Non-narcotic painkiller. 

Sources: National Institutes of Health and DEA. 

[A] DEA classifies controlled substances in schedules I through V. 
Schedule I drugs--including heroin, marijuana, and hallucinogens such 
as LSD--have a high potential for abuse and no federally accepted 
medical use. Schedule II drugs have a high potential for abuse and may 
lead to severe physical or psychological dependence but have a 
currently accepted medical use. Schedules III through V have medical 
uses and successively lower potentials for abuse and dependence. 

[B] Part D plans are not required to cover benzodiazepines. However, 
some plans choose to cover these drugs as an added benefit. 

[C] Methadone is also used for the treatment of narcotic withdrawal 
and dependence. 

[End of table] 

Table 2 shows the breakout by drug class for the approximately 170,000 
Medicare Part D beneficiaries who were prescribed the same class of 
drug by five or more medical practitioners. Because Medicare Part D 
beneficiaries may be receiving multiple classes of prescription drugs 
from five or more medical practitioners, certain beneficiaries may be 
counted in more than one prescription drug class. As shown in table 2, 
hydrocodone and oxycodone were the two prescription drug classes that 
were most prescribed by multiple medical practitioners. Specifically, 
about 97,000 beneficiaries were prescribed hydrocodone by five or more 
medical practitioners. In addition, our analysis found that about 
57,000 Medicare Part D beneficiaries received oxycodone drugs 
prescribed by five or more practitioners. According to DOJ, doctor 
shopping is the primary method to obtain highly addictive prescription 
opioids (e.g., hydrocodone and oxycodone) for illegitimate use. 
[Footnote 21] 

Table 2: Number of Beneficiaries Who Received 1 of 14 Prescription 
Drug Classes from Five or More Prescribers in 2008: 

Amphetamine derivatives (e.g., Adderall): 
DEA controlled: Y; 
Number of prescribers: 5-10: 881; 
Number of prescribers: 11-15: 9; 
Number of prescribers: 16-20: 3; 
Number of prescribers: 21-50: 2; 
Number of prescribers: 51+: [Empty]; 
Number of prescribers: Total: 895; 
Total prescription cost: $1,040,395. 

Benzodiazepine (e.g., Valium and Xanax): 
DEA controlled: Y; 
Number of prescribers: 5-10: 2,437; 
Number of prescribers: 11-15: 17; 
Number of prescribers: 16-20: 4; 
Number of prescribers: 21-50: 2; 
Number of prescribers: 51+: [Empty]; 
Number of prescribers: Total: 2,460; 
Total prescription cost: $372,822. 

Carisoprodol (e.g., Soma): 
DEA controlled: N; 
Number of prescribers: 5-10: 3,026; 
Number of prescribers: 11-15: 51; 
Number of prescribers: 16-20: 4; 
Number of prescribers: 21-50: 2; 
Number of prescribers: 51+: [Empty]; 
Number of prescribers: Total: 3,083; 
Total prescription cost: $592,751. 

Codeine with Acetaminophen (e.g., Tylenol with Codeine): 
DEA controlled: Y; 
Number of prescribers: 5-10: 1,500; 
Number of prescribers: 11-15: 21; 
Number of prescribers: 16-20: 4; 
Number of prescribers: 21-50: [Empty]; 
Number of prescribers: 51+: [Empty]; 
Number of prescribers: Total: 1,525; 
Total prescription cost: $244,930. 

Fentanyl (e.g., Duragesic): 
DEA controlled: Y; 
Number of prescribers: 5-10: 5,043; 
Number of prescribers: 11-15: 24; 
Number of prescribers: 16-20: 8; 
Number of prescribers: 21-50: 2; 
Number of prescribers: 51+: [Empty]; 
Number of prescribers: Total: 5,077; 
Total prescription cost: $19,124,853. 

Hydrocodone (e.g., Vicodin and Lortab): 
DEA controlled: Y; 
Number of prescribers: 5-10: 92,801; 
Number of prescribers: 11-15: 3,553; 
Number of prescribers: 16-20: 700; 
Number of prescribers: 21-50: 335; 
Number of prescribers: 51+: 5; 
Number of prescribers: Total: 97,394; 
Total prescription cost: $18,949,677. 

Hydromorphone (e.g., Dilaudid): 
DEA controlled: Y; 
Number of prescribers: 5-10: 2,453; 
Number of prescribers: 11-15: 77; 
Number of prescribers: 16-20: 13; 
Number of prescribers: 21-50: 8; 
Number of prescribers: 51+: [Empty]; 
Number of prescribers: Total: 2,551; 
Total prescription cost: $1,236,678. 

Meperidine (e.g., Demerol): 
DEA controlled: Y; 
Number of prescribers: 5-10: 149; 
Number of prescribers: 11-15: 8; 
Number of prescribers: 16-20: [Empty]; 
Number of prescribers: 21-50: [Empty]; 
Number of prescribers: 51+: [Empty]; 
Number of prescribers: Total: 157; 
Total prescription cost: $90,236. 

Methadone (e.g., Dolophine and Methadose): 
DEA controlled: Y; 
Number of prescribers: 5-10: 3,414; 
Number of prescribers: 11-15: 9; 
Number of prescribers: 16-20: [Empty]; 
Number of prescribers: 21-50: [Empty]; 
Number of prescribers: 51+: [Empty]; 
Number of prescribers: Total: 3,423; 
Total prescription cost: $859,208. 

Methylphenidate (e.g., Ritalin and Concerta): 
DEA controlled: Y; 
Number of prescribers: 5-10: 740; 
Number of prescribers: 11-15: 2; 
Number of prescribers: 16-20: 1; 
Number of prescribers: 21-50: [Empty]; 
Number of prescribers: 51+: [Empty]; 
Number of prescribers: Total: 743; 
Total prescription cost: $488,759. 

Morphine (e.g., MS Contin and AVINZA): 
DEA controlled: Y; 
Number of prescribers: 5-10: 6,354; 
Number of prescribers: 11-15: 33; 
Number of prescribers: 16-20: 4; 
Number of prescribers: 21-50: [Empty]; 
Number of prescribers: 51+: [Empty]; 
Number of prescribers: Total: 6,391; 
Total prescription cost: $9,311,773. 

Non-Benzodiazepine sleep aids (e.g., Ambien and Lunesta): 
DEA controlled: Y; 
Number of prescribers: 5-10: 4,496; 
Number of prescribers: 11-15: 15; 
Number of prescribers: 16-20: [Empty]; 
Number of prescribers: 21-50: [Empty]; 
Number of prescribers: 51+: [Empty]; 
Number of prescribers: Total: 4,511; 
Total prescription cost: $2,917,465. 

Oxycodone (e.g., Oxycontin and Percodan): 
DEA controlled: Y; 
Number of prescribers: 5-10: 54,183; 
Number of prescribers: 11-15: 1,974; 
Number of prescribers: 16-20: 440; 
Number of prescribers: 21-50: 235; 
Number of prescribers: 51+: 5; 
Number of prescribers: Total: 56,837; 
Total prescription cost: $91,681,281. 

Tramadol (e.g., Ultram and Ultracet): 
DEA controlled: N; 
Number of prescribers: 5-10: 4,346; 
Number of prescribers: 11-15: 134; 
Number of prescribers: 16-20: 33; 
Number of prescribers: 21-50: 14; 
Number of prescribers: 51+: [Empty]; 
Number of prescribers: Total: 4,527; 
Total prescription cost: $1,037,423. 

Total: 
Number of prescribers: 5-10: 181,823; 
Number of prescribers: 11-15: 5,927; 
Number of prescribers: 16-20: 1,214; 
Number of prescribers: 21-50: 600; 
Number of prescribers: 51+: 10; 
Number of prescribers: Total: 189,574; 
Total prescription cost: $147,948,251. 

Sources: GAO and DEA. 

Notes: The totals do not necessarily represent unique beneficiaries. A 
single beneficiary could have been prescribed more than one class of 
drug by more than one prescriber. The number of unique beneficiaries 
represented in this table is 170,029. The maximum number of 
prescribers from which a beneficiary received 1 of the 14 classes of 
prescription drugs was 87. The total beneficiary counts for oxycodone 
and hydrocodone represent 2.8 percent and 1.8 percent of all 
beneficiaries receiving that class of drug, respectively. 

[End of table] 

Examples of Doctor Shopping in Medicare Part D: 

We obtained additional information on 10 of the Medicare Part D 
beneficiaries that showed indications of doctor shopping. In each of 
the 10 cases, we found evidence that the beneficiary was acquiring 
highly abused drugs through doctor shopping. We also found that in 
each example physicians were not aware that their patients were 
receiving drugs prescribed by other prescribers. DEA's definition of 
doctor shopping specifies an individual receiving more of a drug than 
intended by any single physician. In several examples physicians 
stated that they would not have prescribed the drugs if they were 
aware that the patient was receiving the same class of drugs from 
other sources. Table 3 summarizes the 10 examples of doctor shopping 
for prescription drugs, including controlled substances, in the 
Medicare Part D program. The total prescription cost of the drugs 
discussed in table 3 was about $86,000 of which $2,200 was paid 
directly by the beneficiaries in co-payments or deductibles. We are 
referring these beneficiaries to the Medicare Part D fraud contractor, 
as appropriate, for further investigation.[Footnote 22] 

Table 3: Examples of Doctor Shopping of Prescription Drugs in Medicare 
Part D: 

Number 1; 
State: California; 
Class of prescription drug(s): Fentanyl; 
Case details: 
* The beneficiary received prescriptions for a total of 1,397 fentanyl 
patches and pills (a 1,758-day supply) from 21 different prescribers 
in 2008; 
* One physician who treated the beneficiary prescribed fentanyl for 
lower back pain. The beneficiary did not inform the physician that he 
was seeing other doctors. The physician stated that he would not have 
prescribed any controlled substances had he known they were being 
prescribed by other doctors; 
* Another physician who treated the beneficiary from March 2008 
through August 2008 stated that the beneficiary did not disclose that 
he was seeing other doctors and that she would not have prescribed any 
controlled substances had she known they were being prescribed by 
other doctors. In August, 2008, the physician received an alert 
letter[A] from the state PDMP informing her that within a 4-month 
period the beneficiary had received 33 prescriptions for controlled 
substances from 10 different prescribers. After the PDMP alerted the 
physician of these multiple prescribers, the physician informed the 
beneficiary that she would no longer treat him as a patient. 

Number 2; 
State: Georgia; 
Class of prescription drug(s): Oxycodone; 
Case details: 
* The beneficiary received prescriptions for a total of 4,543 
oxycodone pills (a 1,667-day supply) from seven different prescribers 
in 2008; 
* One pharmacist said that because Georgia does not have a PDMP, the 
state is "flooded" with people from Florida, Ohio, and Kentucky trying 
to fill narcotic prescriptions. He stated that many of these people 
become very upset if they are refused their prescriptions. The 
pharmacist stated that the beneficiary recently called and asked if 
the pharmacy had Oxycontin 30mg in stock so that the beneficiary would 
not be wasting time if the drug was not in stock. The pharmacist 
stated that this was strange and told the beneficiary that the 
pharmacy did not have the medicine in stock; 
* A physician who has the beneficiary as a current patient stated that 
they have an appointment monthly and that the beneficiary signed a 
pain management agreement in 2007 prohibiting her from receiving 
controlled substances from any other physicians. The physician stated 
that he had no idea the beneficiary was obtaining narcotics from other 
physicians, and that there is no reason for the beneficiary to be 
seeing more than one physician to obtain narcotics. Based on the 
history the physician had with this patient, he stated that the 
beneficiary is likely selling the extra narcotics as opposed to taking 
them. 

Number 3; 
State: Georgia; 
Class of prescription drug(s): Carisoprodol Hydrocodone Oxycodone; 
Case details: 
* The beneficiary received prescriptions for a total of 1,984 
carisoprodol pills (an 894-day supply), a total of 1,850 hydrocodone 
pills (a 617-day supply), and a total of 1,800 oxycodone pills (a 680-
day supply) from 12 different prescribers in 2008; 
* One pharmacy has a note in its system to verify the beneficiary's 
prescriptions because of suspected prior forgeries. A pharmacy 
employee, originally from Virginia, told us that it was very easy to 
forge prescriptions in Georgia because there is no requirement for 
prescriptions to be printed on security paper, which makes it easy for 
someone to produce a fraudulent prescription at home; 
* One physician, who has been treating the beneficiary for about 7 
years, learned about the patient's prior doctor shopping when the 
patient tried to refill a prescription from another doctor. The 
physician stated that he confronted the beneficiary about the concern 
and had him sign a pain management agreement prohibiting him from 
receiving controlled substances from any other physician and requiring 
that he get pain prescriptions filled at only one pharmacy. Although 
the physician discovered that the agreement was violated, the 
physician did not stop treating the beneficiary because the 
beneficiary had legitimate pain and needed treatment. Instead, the 
physician counseled the beneficiary and continues to provide medical 
services; 
* Another physician has seen the beneficiary approximately once each 
month for the past several years. Although the physician asked the 
beneficiary, during each office visit, whether he was seeing other 
doctors or obtaining narcotics from any other source, the beneficiary 
denied doing so. The physician stated that although the beneficiary 
has legitimate need for narcotic medication for pain, there is no need 
for the beneficiary to obtain narcotics from more than one physician; 
* A third physician treated the beneficiary from 2007 to 2009 at a 
clinic outside of her regular practice where she periodically worked. 
At that clinic, the physician discovered that the beneficiary was 
receiving drugs from another physician. Both the physician and the 
clinic discharged the beneficiary from their practices because the 
beneficiary failed to disclose that he was seeing other physicians. 

Number 4; 
State: Georgia; 
Class of prescription drug(s): Carisoprodol, Oxycodone; 
Case details: 
* The beneficiary received prescriptions for a total of 3,846 
oxycodone pills (a 991-day supply) and a total of 2,220 carisoprodol 
pills (a 740-day supply) from 14 different prescribers in 2008; 
* A physician prescribed the controlled substances to treat pain that 
the beneficiary suffered after a fall. The physician stated that pain 
is subjective and that a physician cannot always tell if a patient is 
exaggerating his or her pain level to obtain more narcotics; 
* The physician treated the beneficiary from 2006 to 2009 and required 
that the beneficiary sign an annual pain management agreement. The 
beneficiary did not inform the physician about seeing other doctors or 
receiving narcotics from them; 
* The doctor stated that he conducts random drug tests of his patients 
and that the beneficiary was never found to have illicit drugs in her 
system. However, on one occasion, a drug test revealed that the 
beneficiary had a drug that was not prescribed by him. The beneficiary 
told the physician of a recent dentist visit during which the dentist 
prescribed the drug; 
* The physician did state that the beneficiary called him in 2009 and 
stated that the current drug regime was not controlling the pain. The 
beneficiary requested that the physician prescribe Percocet, which the 
physician refused. The physician stated that this may be the reason 
why the beneficiary quit going to him for medical visits. 

Number 5; 
State: Georgia; 
Class of prescription drug(s): Oxycodone; 
Case details: 
* The beneficiary received prescriptions for a total of 3,655 
oxycodone pills (a 1,679-day supply) from 58 different prescribers in 
2008. The beneficiary received a prescription for at least 1 of the 14 
selected drugs from at least 66 different prescribers, and she filled 
her prescriptions at 45 different pharmacies in 2008; 
* A pharmacy discovered that the beneficiary was forging a 
prescription from a physician. The pharmacy has noted in its system 
that its store and other pharmacies in the chain should refuse to fill 
controlled substances prescriptions for this beneficiary; 
* Another pharmacy refused to fill a prescription for the beneficiary, 
after believing that the beneficiary tried to fill a forged 
prescription at the store. The beneficiary has not returned to the 
store since that refusal; 
* A physician who treated the beneficiary frequently saw her and was 
repeatedly asked for early refills of Oxycontin prescriptions. After 
the physician would no longer prescribe Oxycontin, the beneficiary's 
medical visits to him ceased. The beneficiary did not inform the 
physician about seeing other physicians. The physician would not have 
prescribed any controlled substances had he known they were being 
prescribed by other physicians; 
* Another physician stated that he was suspicious of the beneficiary's 
need for the drugs because (1) the beneficiary stated a desire for 
Oxycontin because of an allergy to other drugs and (2) the beneficiary 
refused to see a specialist despite his repeated directions. The 
beneficiary quit seeing the physician after the physician refused to 
prescribe any more narcotics. The physician was not aware of any 
attempted forgeries, but stated that he would not be surprised because 
it is easy to forge prescriptions in Georgia. The physician stated 
that Georgia has no requirements that prescriptions be written on any 
type of special security paper and that an individual can simply print 
or copy a prescription at home using a personal computer and regular 
computer paper. 

Number 6; 
State: Massachusetts; 
Class of prescription drug(s): Oxycodone; 
Case details: 
* The beneficiary received prescriptions for a total of 1,252 
oxycodone pills (a 455-day supply) from 24 different prescribers in 
2008; 
* A physician treated the beneficiary from February 2008 through 
August 2008. In May 2008, the physician stated that he received an 
alert letter from the Medicare Part D plan sponsor that showed the 
beneficiary was obtaining prescriptions for Oxycontin from 10 other 
physicians. The beneficiary did not disclose to the physician that she 
was receiving medications from other physicians. The physician 
informed the beneficiary that he will no longer prescribe narcotics. 
The physician stated that at about that time, the beneficiary's office 
visits ceased; 
* Another doctor treated the beneficiary from August 2008 through 
March 2009. The doctor had required the beneficiary to sign a pain 
management contract that required her to only obtain narcotics from 
his practice. The doctor discharged the beneficiary from his practice 
after the beneficiary tested positive for cocaine and hydrocodone 
during a random drug screening. Subsequent to the discharge, the 
doctor received an alert letter from the PDMP listing the various 
doctors being visited and the medications being prescribed. The 
physician stated that the amount of narcotics being obtained was 
medically unnecessary. 

Number 7; 
State: Maryland; 
Class of prescription drug(s): Fentanyl; 
Case details: 
* The beneficiary received prescriptions for a total of 280 fentanyl 
patches and pills (a 761-day supply) in 2008 from 12 different 
prescribers; 
* The beneficiary's current physician stated that the beneficiary has 
legitimate medical problems that warrant the use of pain medication. 
However, after reviewing pharmacy reports on the prescriptions filled 
for the patient, the physician did not think that there was a 
legitimate medical reason to obtain so much pain medication. The 
physician was unaware that the beneficiary was seeing other doctors 
and obtaining additional prescriptions for controlled substances; 
* The beneficiary was also a patient at a short-term rehabilitation 
facility. The facility's director of nursing stated that when the 
beneficiary was admitted, the beneficiary "threw a fit" and threatened 
to walk out if the facility did not provide him intravenous Dilaudid. 
The director of nursing stated that numerous individuals intentionally 
get themselves admitted to nursing homes or rehabilitation centers 
because they feel it is easier to obtain narcotics; 
* A physician at the rehabilitation facility stated that he prescribed 
the beneficiary fentanyl even though the medical chart indicated that 
beneficiary was addicted to opiates. According to the physician, the 
facility's protocols require physicians to provide patients with a 30-
day supply of the medication they were receiving in the hospital to 
provide continuity of care. 

Number 8; 
State: Maryland; 
Class of prescription drug(s): Oxycodone; 
Case details: 
* The beneficiary received prescriptions for a total of 5923 oxycodone 
pills (a 1,450-day supply) from 11 different prescribers in 2008; 
* One physician treated the beneficiary for chronic pain beginning in 
January 2008, and had the beneficiary sign a pain management agreement 
that among other things required the beneficiary to receive narcotics 
only from him. The physician received an alert letter from the Part D 
plan sponsor in October 2009 listing all the medications that were 
dispensed to the beneficiary over a 9-month period. At that time, the 
physician discharged the beneficiary from the practice; 
* Another physician also received an alert from the Part D plan 
sponsor. The second physician confronted the beneficiary with the data 
about other narcotic prescribers. The physician stated that the 
beneficiary said it was a case of mistaken identity. At that time, the 
physician stated that he could no longer continue to treat the 
beneficiary. However, the beneficiary returned a few months later and 
claimed that a pain management specialist would only accept cash and 
thus the beneficiary could no longer afford to go there. The physician 
stated that he treated the beneficiary for a few months until the 
beneficiary found another pain specialist. However, the physician 
stated that he no longer prescribes narcotics to the beneficiary and 
that there is no legitimate medical reason for the beneficiary to see 
multiple doctors or obtain additional narcotics. 

Number 9; 
State: Texas; 
Class of prescription drug(s): Hydrocodone; 
Case details: 
* The beneficiary received prescriptions for a total of 1,289 
hydrocodone pills (a 490-day supply) from 22 different prescribers in 
2008; 
* The beneficiary signed a pain management agreement with the current 
physician, but the physician did not know that the beneficiary was 
seeing other physicians. The physician stated there was no medical 
necessity for the drugs and that there was no way possible that the 
beneficiary was consuming the dosages of the prescribed drugs as 
indicated; 
* The beneficiary was required to sign a patient responsibility 
agreement at another practice. This agreement states that a patient 
must disclose all medications he or she is currently taking and other 
prescriptions received. The beneficiary's medical file did not 
indicate that the beneficiary was seeing other physicians, and his 
physician did not know that he was receiving controlled substances 
from other physicians. Had the physician known, the beneficiary would 
have been "fired." The beneficiary did stop seeking medical treatment 
from the physician for unknown reasons. 

Number 10; 
State: Texas; 
Class of prescription drug(s): Hydrocodone; 
Case details: 
* The beneficiary received prescriptions for a total of 4,574 
hydrocodone pills (a 994-day supply) from 25 different prescribers in 
2008; 
* A previous physician stated that the beneficiary was obligated to 
inform him about receiving other prescriptions for controlled 
substances. The physician stated that he did not know that other 
physicians were prescribing narcotics to the beneficiary. The 
physician stated that it was medically unnecessary, and possibly 
dangerous, to consume the amount of narcotics obtained by the 
beneficiary. Had he been informed that the beneficiary was receiving 
narcotics from other doctors, the physician would have ceased 
prescribing the drugs. 

Source: GAO. 

[A] Prescribers can receive alert letters from state PDMPs and from 
Part D plan sponsors. 

[End of table] 

Systems Are in Place to Identify Inappropriate Drug Use, but Measures 
to Stop the Activity Are Limited: 

CMS, through its Part D plan sponsors, does not limit access to 
hydrocodone, oxycodone, and other highly abused drugs for 
beneficiaries who are known doctor shoppers. Although systems are in 
place to identify individuals with doctor shopping behavior, according 
to CMS Part D program officials, federal law does not authorize Part D 
plans to restrict the access of these individuals. CMS requires Part D 
plans to perform retrospective drug utilization review (DUR) analysis 
to identify prior inappropriate or unnecessary medication use. By 
analyzing historical prescription claims data, the drug plans can 
identify individuals who are likely obtaining excessive amounts of 
highly abused drugs or potentially seeking such drugs from multiple 
medical practitioners. However, unless restrictions are placed on 
these individuals, the current system will not prevent these known 
abusers from continuing these practices. 

If a beneficiary is found to be inappropriately obtaining abused 
drugs, CMS guidance states that Part D plan sponsors would provide 
practitioner and beneficiary education as appropriate. For instance, 
if a potential doctor shopper is identified, intervention letters 
would be sent to all prescribers who ordered the drug type for that 
individual. An intervention might consist of an informational letter 
to the medical practitioner; a response form for the medical 
practitioner to complete, along with a preaddressed return envelope; 
and a patient drug profile. However, the effectiveness of such a 
notification may be limited because the physicians can overlook the 
intervention letters, or if a request for a prescription is denied by 
one physician, the beneficiary can go to another physician for the 
desired prescription. 

Although not currently used in the Medicare Part D program, officials 
from the Part D plan sponsors we interviewed stated that additional 
controls already in place in the Medicaid program and in some private 
sector plans could be used to better restrict the dispensing of abused 
drugs, such as hydrocodone and oxycodone, to individuals identified as 
doctor shoppers through detecting a pattern of abuse during 
retrospective analysis. Such programs employ a restricted recipient 
program, where prescription drug plans restrict beneficiaries who have 
been identified as drug abusers to one prescriber, one pharmacy, or 
both for receiving prescriptions. However, according to CMS policy 
officials, the restricted recipient program cannot be utilized in the 
Medicare Part D program because MMA did not authorize CMS to establish 
such restrictions on beneficiaries. As such, Part D plan sponsors are 
prevented from implementing these controls on specific individuals to 
prevent doctor shopping. There are issues to consider with a 
restricted recipient program, such as potentially denying legitimate 
drug needs and unknown costs for administration. These costs include 
developing and implementing criteria and procedures for placing 
individuals in the program, allowing them to change providers as 
appropriate, and ultimately releasing them from the program. 

Effective retrospective DURs require prescription drug plans to be 
able to share information about individuals identified as doctor 
shoppers with other Part D plans, as appropriate. Even if a restricted 
recipient program were implemented, according to CMS officials, 
Medicare Part D plan sponsors are not allowed to share beneficiary 
information with other plans.[Footnote 23] As a result, a Medicare 
Part D plan sponsor cannot forewarn another Medicare Part D plan 
sponsor when an identified doctor shopper has left its plan and 
enrolled in another. Because Medicare Part D beneficiaries can change 
prescription drug plans on at least a yearly basis,[Footnote 24] 
beneficiaries may be able to switch plans and continue their doctor 
shopping activity. Thus, to prevent known doctor shoppers from 
circumventing a restricted recipient program, a mechanism would also 
need to be established that allows CMS or its fraud contractor to 
inform the new plan of the doctor shopping activities of the 
beneficiary. Without such notification, beneficiaries will be able to 
bypass a restricted recipient program merely by switching prescription 
drug plans. 

Conclusion: 

Prescription drug abuse is a national problem and appears to exist in 
the Medicare Part D program. In addition to the costs to society of 
addiction, overdose, death, and related criminal activities, taxpayers 
and Medicare beneficiaries bear the additional costs for excessive 
prescriptions obtained to supply an addiction or for diversion to 
illicit drug distributors. Protecting patient health and combating the 
illegal diversion or abusive usage of prescription drugs, while 
ensuring that the pharmaceuticals remain available for those with 
legitimate medical needs, involves the efforts of both the 
prescription drug plans and the federal government. Although systems 
are in place to identify inappropriate drug use, measures to stop the 
activity are limited. The restricted recipient program is one tool 
that could be used to prevent doctor shopping in the Medicare Part D 
program. If such a tool were implemented for Medicare Part D, CMS 
would also need a mechanism to share information about restricted 
recipients between plans. This would allow a new plan to be informed 
about the beneficiary's prescription use and to take appropriate 
action. In considering a restricted recipient program, CMS could 
utilize the experience of Medicaid and private sector programs to 
facilitate implementation issues and address the costs and benefits of 
such a program. CMS could also consider piloting a restricted 
recipient program focusing on hydrocodone and oxycodone, the two drug 
classes where we identified the largest potential doctor shopping 
activity. Increased controls over dispensing highly abusive drugs can 
help reduce the risk that individuals will use Medicare to facilitate 
their dangerous drug activities, which increases the cost of the 
program and jeopardizes patient care. As part of any evaluation, 
additional controls, such as the restricted recipient program, may 
require additional legal review and based on that review may require 
congressional authority to implement. 

Recommendation for Executive Action: 

To improve efforts to address doctor shopping by beneficiaries of 
highly abused prescription drugs, we recommend that the Administrator 
of CMS review our findings, evaluate the existing DUR program, and 
consider additional steps such as a restricted recipient program for 
Medicare Part D that would limit these beneficiaries to one 
prescriber, one pharmacy, or both for receiving prescriptions. CMS 
should consider the experiences from Medicaid and private sector use 
of such restricted recipient programs, including weighing the 
potential costs and benefits of instituting the control. CMS could 
consider piloting such a program with a focus on hydrocodone and 
oxycodone, the two drug classes where we identified the largest 
potential doctor shopping activity. Along with a restricted recipient 
program, CMS should also consider facilitating the sharing of 
information on identified doctor shoppers among the Part D drug plan 
sponsors so that those beneficiaries cannot circumvent the program by 
switching prescription drug plans. In considering such controls, CMS 
should seek congressional authority as appropriate. 

Agency Comments and Our Evaluation: 

We provided a draft of this report to CMS and DOJ for comment. DOJ 
stated that it did not have comments on the report. CMS's comments are 
reprinted in appendix I, and its technical comments were incorporated 
in the report as appropriate. 

CMS agreed with our overall recommendation to improve efforts to curb 
overutilization in Part D, but disagreed that a restricted recipient 
program is necessarily the appropriate control for the Part D program. 
CMS stated that GAO provided no evidence that a restricted recipient 
program would be more effective than existing DUR requirements. CMS 
also requested the data from the report to consider whether these data 
indicate a failure of Part D plan sponsors to effectively implement 
concurrent or point-of-sale DURs or whether there are additional 
approaches to supplement DURs while not jeopardizing patient access to 
care. It also stated that CMS officials are undertaking additional 
evaluation of MEDIC data on potential overutilization to identify 
potential solutions and that they will issue program guidance to Part 
D sponsors on any best practices and develop an internal monitoring 
strategy. 

We appreciate that CMS agrees with us that more efforts could be 
undertaken to curb overutilization in the Part D program, and we 
recognize its challenge in balancing the need to combat fraud, waste, 
and abuse with the program's goal of providing beneficiaries 
sufficient access to medically necessary prescription drugs. To 
reflect the issues raised by CMS, we revised our recommendation to 
include other actions that may be taken by CMS to address 
overutilization of prescription drugs. CMS guidance states that Part D 
plans must perform retrospective DUR analysis to identify 
inappropriate prescriptions and provide education, such as alert 
letters, to the prescribers involved. However, our case study examples 
showed that the receipt of such letters by prior prescribers did not 
prevent inappropriate prescriptions from being obtained from other 
prescribers. We support CMS looking into both enhanced point-of-sale 
and retrospective controls and related actions to address 
overutilization and questionable access to specific drugs. 

CMS said that GAO provided no evidence that a restricted recipient 
program would be more effective than existing DUR requirements. 
However, our intent is not to prescribe a restricted recipient program 
as the only solution, but instead for CMS to consider utilizing it 
along with existing controls. The Part D plan sponsor officials we 
interviewed stated that a restricted recipient program, already in 
place in Medicaid and the private sector, could better restrict the 
dispensing of abused drugs. A restricted recipient program is an 
additional control that can be used for known abusers identified by 
retrospective DUR while not jeopardizing legitimate patient access to 
care. Thus, a restricted recipient program warrants further 
consideration by CMS. 

We used CMS's own prescription drug paid claims data for our analysis. 
We are referring the examples in table 1 to the MEDIC as appropriate. 
We are also referring to the MEDIC the identities of other more 
egregious potential cases we identified through our analysis. 
According to CMS paid claims data, these individuals visited 40 or 
more prescribers in 2008 for a single class of drug and had 
overlapping prescriptions for the same drug class from different 
prescribers. 

As agreed with your offices, unless you publicly announce the contents 
of this report earlier, we plan no further distribution until 30 days 
from the report date. At that time, we will send copies to the 
Secretary of Health and Human Services, the Attorney General, and 
other interested parties. In addition, the report will be available at 
no charge on the GAO website at [hyperlink, http://www.gao.gov]. 

If you or your staff have questions about this report, please contact 
me at (202) 512-6722 or kutzg@gao.gov. Contact points for our Offices 
of Congressional Relations and Public Affairs may be found on the last 
page of this report. GAO staff members who made key contributions to 
this report are listed in appendix II. 

Signed by: 

Gregory D. Kutz: 
Director, Forensic Audits and Investigative Services: 

[End of section] 

Appendix I: Comments from the Centers for Medicare & Medicaid Services: 

Department Of Health & Human Services: 
Office of The Secretary: 
Assistant Secretary for Legislation: 
Washington, DC 20201: 

August 6, 2011: 

Greg Kutz, Director: 
Forensic Audits and Special Investigations: 
U.S. Government Accountability Office: 
441 G Street N.W. 
Washington, DC 20548: 

Dear Mr. Kutz: 

Attached are comments on the U.S. Government Accountability Office's 
(GAO) draft report entitled: "Medicare Part D: Instances of 
Questionable Access to Prescription Drugs" (GA0-11-699). 

The Department appreciates the opportunity to review this report 
before its publication. 

Sincerely, 

Signed by: 

Jim R. Esquea: 
Assistant Secretary for Legislation: 

Attachment: 

[End of letter] 

General Comments Of The Department Of Health And Human Services (HHS) 
On The Government Accountability Office'S (GAO) Draft Report Entitled, 
"Medicare Part D - Instances Of Questionable Access To Prescription 
Drugs" (GAO-11-699): 

Thank you for the opportunity to review and comment on this draft 
report. We appreciate GAO's efforts in working with the Centers for 
Medicare and Medicaid Services (CMS) to help determine if Medicare 
beneficiaries are inappropriately accessing frequently abused 
prescription drugs. CMS shares the concerns of the Congressional 
requesters that prescription drug abuse is a serious and growing 
public health problem. 

High utilization of pain medications is not necessarily an indication 
of abuse, but could be an indication of poorly coordinated care in the 
treatment of pain symptoms. GAO acknowledged that the presence of 
multiple prescribers during the course of the year dots not 
necessarily indicate abuse or doctor shopping. For example, of the 
170,000 beneficiaries identified, the GAO did not determine how many 
of these beneficiaries had overlapping prescriptions for the same 
class of drugs from different prescribers - different prescriptions 
that were filled concurrently rather than sequentially during the 
course of the year. GAO also did not identify how many of these 
beneficiaries using multiple prescribers for the same class of drugs 
filled prescriptions in excess of dosages recommended by the Food and 
Drug Administration (FDA). 

GAO recognizes beneficiaries may have justifiable reasons for 
receiving prescriptions from multiple providers, such as receiving 
care from multiple medical practitioners in a medical group. Even with 
the limitations on GAO's data analysis, the report shows that some 
Part D sponsors failed to implement appropriate controls against the 
abuse or misuse of prescription drugs, including controlled substances.
CMS agrees with the GAO that more efforts could be undertaken to curb 
overutilization in the Medicare Prescription Drug Program. We support 
solutions that curb not only the Federal costs of excessive 
prescription drug use, but improve the overall health and safety of 
Medicare beneficiaries. As CMS provides in more detail below, CMS must 
balance the need to combat fraud, waste and abuse and at the same time 
ensure our beneficiaries have sufficient access to medically necessary 
prescription drugs. 

GAO Recommendation: 

To improve efforts to address doctor shopping by beneficiaries of 
highly abused prescriptions drugs, GAO recommends that CMS review 
GAO's findings and consider a restricted recipient program for 
Medicare Part D that would limit these beneficiaries to one 
prescriber, one pharmacy or both for receiving prescriptions. Along 
with a restricted recipient program CMS should consider, ,facilitating 
the sharing of identified doctor shoppers among the Part D drug plan 
sponsors so that those beneficiaries cannot circumvent the program by 
switching prescription drug plans. In considering this control, CMS 
should seek congressional authority as appropriate. 

CMS Response: 

CMS concurs with GAO's overall recommendation to improve efforts to 
curb overutilization in Part D, but disagrees that a restricted 
recipient program is necessarily the appropriate control for the Part 
D program. GAO provides no evidence in the report that a restricted 
recipient program would be more effective in preventing prescription 
drug abuse than current drug utilization review (DUR) requirements. 
These DUR controls are designed to perform safety and utilization 
edits at point-of-sale and retrospective of the dispensing event and 
provide Part D sponsors the tools necessary to prevent beneficiaries 
from using the Part D benefit to abuse or misuse prescription drugs 
without restricting their access to certain physicians or pharmacies. 

We would like to evaluate the data from this report on questionable 
overutilization and consider whether this data indicates a failure of 
Part D plan sponsors to effectively implement concurrent DUR that 
would prevent overutilization and abuse and whether there are 
additional approaches to supplement DUR that will not jeopardize 
patient access to care. Therefore, we request that GAO provide CMS 
with the data used for this study. 

In addition, CMS will: 

1. Undertake additional evaluation of available Medicare Drug 
Integrity Contractor (MEDIC) data and findings on overutilization and 
questionable access to specific drugs to identify potential solutions 
appropriate for the Part D program. 

2. Issue program guidance to Part D sponsors on any best practices or 
requirements that are identified through our evaluation of the 
overutilization data and develop an internal monitoring strategy. 

We support solutions that will retain beneficiary access to care, curb 
not only the Federal costs of excessive prescription drug use, but 
also decrease the overall medical costs of drug abuse-related behavior 
such as costs of treating communicable diseases and injuries from drug-
related violence. We thank you for the opportunity to respond to this 
report and look forward to continue working with the GAO to improve 
the Medicare program. 

Technical Comments Of The Department Of Health And Human Services 
(HHS) On The Government Accountability Office's (GAO) Draft Report 
Entitled, "Medicare Part D — Instances Of Ouestionable Access To 
Prescription Drugs" (GA0-11-699): 

Page 8 - GAO asserts that about 30,000 beneficiaries on disability 
receiving prescriptions for drugs in the 14 classes had "diagnosis 
codes relating solely to mental impairments." It appears these 
diagnosis codes are from Social Security Administration's (SSA) 
disability files and as such do not include diagnoses for conditions 
unrelated to SSA's disability determination for which they may be 
receiving treatment under Medicare. Without a review of the diagnoses 
on the beneficiaries' Part A and Part B claims, it is inappropriate 
for GAO to intimate that these beneficiaries do not have diagnoses for 
conditions that might be appropriately be treated by the prescription 
drugs in the 14 classes under review. 

Footnote 25 - CMS recommends rewording to state: "This statement is 
the opinion of CMS policy officials and is not a legal opinion 
rendered by the IBIS Office of General Counsel." 

[End of section] 

Appendix II: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Gregory D. Kutz, (202) 512-6722 or kutzg@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, the following individuals made 
major contributions to this report: Erika Axelson, Assistant Director; 
Matthew Harris, Assistant Director; Matthew Valenta, Assistant 
Director; John Ahern; Gary Bianchi; Scott Clayton; Eric Eskew; Maria 
Kabiling; James Murphy; Jonathon Oldmixon; Philip Reiff; Barry 
Shillito; and April Van Cleef. 

[End of section] 

Footnotes: 

[1] GAO, Medicaid: Fraud and Abuse Related to Controlled Substances 
Identified in Selected States, [hyperlink, 
http://www.gao.gov/products/GAO-09-957] (Washington, D.C.: Sept. 9, 
2009). 

[2] U.S. House of Representatives, Subcommittee on Criminal Justice, 
Drug Policy, and Human Resources, Government Reform Committee, July 
26, 2006 (testimony of Mr. Joseph T. Rannazzisi, Deputy Assistant 
Administrator Office of Diversion Control, Drug Enforcement 
Administration). 

[3] Our analysis covered Medicare Part D claims for calendar year 
2008. As of March 2008, Medicare Part D had 25 million enrollees. Net 
operating costs for fiscal year 2008 were $43 billion. 

[4] GAO's audits and evaluations identify federal programs and 
operations that we determine are high risk because of their greater 
vulnerabilities to fraud, waste, abuse, and mismanagement. See GAO, 
High-Risk Series: An Update, [hyperlink, 
http://www.gao.gov/products/GAO-11-278] (Washington, D.C.: February 
2011). 

[5] U.S. Senate, Subcommittee on Federal Financial Management, 
Government Information, Federal Services, and International Security, 
Committee on Homeland Security and Governmental Affairs, July 15, 2010 
(testimony of Mr. Robert Vito, Acting Assistant Inspector General for 
CMS Audits, Office of the Inspector General, U.S. Department of Health 
and Human Services), and GAO, Medicare Part D: CMS Oversight of Part D 
Sponsors' Fraud and Abuse Programs Has Been Limited, but CMS Plans 
Oversight Expansion, [hyperlink, 
http://www.gao.gov/products/GAO-10-481T] (Washington, D.C.: Mar. 3, 
2010). Also see U.S. House of Representatives, Ways and Means 
Subcommittees on Health and Oversight, 110th Cong., March 8, 2007 
(testimony of Daniel R. Levinson, HHS Inspector General), and U.S. 
House of Representatives, Oversight and Government Reform Committee, 
February 9, 2007 (testimony of Lewis Morris, Chief Counsel to the HHS 
Inspector General). 

[6] From the calendar year 2008 claims, we used those with either a 
National Provider Identifier (NPI) or a DEA number identifying the 
prescriber. For those claims with a DEA number, we assigned the 
corresponding NPI number. Based on this NPI number assignment, we 
determined the total number of different prescribers from which each 
beneficiary received prescriptions. We did not evaluate the number of 
Medicare beneficiaries who had fewer than five prescribers for 1 class 
of drugs but in total may have had five or more prescribers for any of 
the 14 highly abused classes of drugs. 

[7] For the 14 classes of drugs, the extent of claims with NPI group 
level only identifiers was 1.2 percent. 

[8] Neither Georgia nor Maryland had a prescription drug monitoring 
program in place in 2008. 

[9] Data validation edits include (1) tests to see if numeric fields 
contain non-numeric data and (2) tests on a value to see if it falls 
within the range established for the data element. 

[10] Pub. L. No. 91-513, Title II, 84 Stat. 1236, 1242 (1970). 

[11] 21 C.F.R. § 1304.33 lists the specific controlled substances to 
be included in these reports from manufacturers and distributors, 
while 21 C.F.R. § 1304.55 covers the information in reports by online 
pharmacies. 

[12] An Internet pharmacy is required to report the total quantity of 
each controlled substance that the pharmacy dispenses each month, but 
not each patient transaction. 

[13] GAO, Prescription Drugs: State Monitoring Programs Provide Useful 
Tool to Reduce Diversion, [hyperlink, 
http://www.gao.gov/products/GAO-02-634] (Washington, D.C.: May 17, 
2002). 

[14] DOJ, National Prescription Drug Threat Assessment 2009 (NPDTA 09) 
(Johnstown, Pa.: April 2009). 

[15] Medicare Part D is financed from general revenues, beneficiary 
premiums, and state contributions for Medicare beneficiaries who are 
also eligible for Medicaid. A beneficiary premium is set to cover 
approximately 25 percent of the cost of standard drug coverage. 

[16] The $148 million in prescription costs represents about 5 percent 
of total Medicare Part D prescription costs for these14 classes of 
highly abused drugs. The prescription drug costs included in this 
study do not include related costs associated with obtaining 
prescriptions, such as the corresponding visits to the doctor's office 
and emergency room. These costs are billed separately from the 
prescription drug claims. 

[17] When Medicare Part D was established, it replaced Medicaid as the 
primary source of drug coverage for beneficiaries with coverage under 
both programs--referred to as dual-eligible beneficiaries. Part D 
provides substantial premium and cost-sharing assistance through the 
LICS for dual-eligible beneficiaries and other low-income 
beneficiaries. The amount of the subsidy for premiums, deductibles, co-
payments, and catastrophic coverage varies depending on income and 
resources. 

[18] Our threshold of visiting five or more practitioners excludes 
those who successfully doctor shop by visiting fewer than five 
practitioners on a regular basis. For example, a Medicare beneficiary 
can regularly receive overlapping prescriptions of abused drugs by 
visiting as few as two practitioners. 

[19] DOJ, National Prescription Drug Threat Assessment 2009 (NPDTA 09). 

[20] DOJ, National Prescription Drug Threat Assessment 2009 (NPDTA 09). 

[21] DOJ, National Prescription Drug Threat Assessment 2010 (NPDTA 10) 
(Johnstown, Pa.: February 2010). 

[22] CMS guidance directs Part D plans to refer cases of potential 
fraud directly to the Medicare Part D fraud contractor. 

[23] However, pursuant to 45 C.F.R. § 164.506(c)(4)(ii), a Medicare 
Part D sponsor may disclose protected health information to another 
Medicare Part D sponsor if each sponsor either has or had a 
relationship with the individual who is the subject of the protected 
health information being requested, the protected health information 
pertains to such relationship, and the disclosure is for the purpose 
of health care fraud and abuse detection or compliance. CMS policy 
officials were not able to explain why this would not apply to doctor 
shopping. 

[24] LICS recipients are allowed to switch plans monthly. In 2010, 33 
percent of Part D beneficiaries were enrolled under the LICS. 

[End of section] 

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