Auditing Prescribing Practices in Opiate Enforcement Cases

ALN Nurse Consultants have experience in providing audit support in investigations related to allegations such as reckless prescribing of narcotics and wrongful death related to overdose from prescribed controlled substances. ALN is on the leading edge of the opiate investigation trend and has significant experience in auditing provider prescribing practices.

In the featured case, ALN was retained to evaluate the care and services provided by a physician under investigation by the Department of Health, Office of General Counsel.

The ALN team mobilized and created a work product to support extraction of the necessary information—on a tight deadline with a massive amount of patient records needing evaluation. Since the trend in allegations of reckless prescribing is evolving, ALN created a custom template for the client which helped the legal team more clearly understand the facts of the case and provide easy access to the details related to the allegations. Our nurse consultants were able to review medical records for sixty patients, over 1,800 patient encounters amounting to over 8,200 pages of records, with just a two-week turnaround. With each patient, ALN zeroed in on whether the provider documented the etiology and objective findings of pain; followed the state’s standard of care in prescribing with regard to the applicable case law; checked the Controlled Substance Monitoring Database (CSMD); fulfilled other required testing to screen for potential addiction; and considered other therapeutic treatments for the patients’ pain. Our nurse reviewers also audited the state pharmaceutical database to evaluate for controlled substances prescribed by other providers during the time the patients were under the defendant physician’s care. Our reviewers analyzed more than 400 narcotic log entries for instances of “other prescribing” providers.

ALN created an individualized work product for our client which very clearly condensed the most crucial evidence into a quick access format, which helped facilitate identification of next best steps in the investigation.

An essential component of analysis when auditing provider prescribing patterns is determining the Morphine milligram daily equivalents (MME) for each patient encounter and the MME trend over time. According to the CDC, “higher dosages of opioids are associated with higher risk of overdose and death, even with relatively low dosages (20-50 MME per day).”[1] Dosages at or above 50 MME/day increase the risk for overdose by at least two times. Updates to state legislation are ongoing with regard to the provider and pharmacist responsibility in recording and monitoring the patient’s MME. In the featured case, the patient’s MME started at 30 and reached levels up to 180 with multiple combinations of opioids prescribed.

Few legal nurse consulting firms have experience in DOJ/OIG investigations, even though this is a burgeoning section of health law litigation in the U.S. Auditing provider opioid prescribing patterns can be a massive undertaking. ALN has the expertise and resources to support the investigative team in cases where inappropriate prescribing is suspected or alleged. Although the outcome of any audit may not always be favorable, the information a legal nurse consultant can unearth is a key piece in helping determine next best steps in opioid matters.

[1] https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf