The Rising Use of Opioids

Fraud and abuse for prescription drugs is a hot topic, and in particular the rising use of opioids. Sadly, an increasing number of people in the US have died from opioid overdoses, many of whom could have been saved if they hadn’t been given unnecessary access the prescriptions directly from a provider or been able to find them illegally.

Prevention and detection of potential opioid misuse are both key elements to end this rising epidemic. Sometimes healthcare professionals are duped into complicity. Other times, they are willing participants in the abuse cycle. In both cases, machine learning and detection can be used to help uncover and stop the abuse.

Sharecare Payment Integrity (formerly WhiteHatAI) has developed the revolutionary capability to provide timely and cost-effective solutions with its data analytics system called the Centaur. The Centaur solution can be applied directly to prescription claims utilizing internal and external prescription databases while at the same time comparing claims against past claims data. But most importantly, the Centaur “learns” every time that it works on a claim. And it learns like a new claims’ auditor would learn from a seasoned auditing veteran. Every time the Centaur interacts with its human partner looking for prescription drug abuse, it gets closer and closer to independently finding the patterns and schemes that fraudsters are using to stay a step (or two or three) ahead of the law.

With the assistance of the Centaur, auditors, regulators and law enforcement could significantly reduce the time and energy it takes to find the increasing number of fraudulent claims that, with the overwhelming number of claims being processed every day, are literally needles in a haystack. Some of the information to stop drug and opioids abuse exists but identifying it in a timely manner is a huge challenge. The abuse and misuse need to be identified immediately and it is vital that this happens as early in the claims payment process to effectively shut down the overuse and abuse of these drugs.

Patients, and fake patients, often travel long distances to get prescriptions filled. They see more than one physician and get more than one prescription of the same drug. Some physicians prescribe at an astonishingly high opioid rate than one might expect for their specialty (dermatology, for example). The Centaur can quickly uncover those patterns to help curb the prescription drug epidemic that is killing our citizens and strapping our medical resources. We need to find and utilize innovative solutions before it’s too late.

Request Your Claims Denial Impact Calculator