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We Protect Those Who Can't Protect Themselves

May 17, 2013

From the desk of Michael Testa, senior manager, Fraud Analytics

As a member of the Fraud, Waste & Abuse Services team at Express Scripts, I am on the front lines. After years of working on cases, sometimes they blur together. But then there are the ones that stand out, especially those that involve the most innocent and vulnerable: children.

We have seen cases of adults stealing or using a child's medical identification to obtain prescription medications to feed an addiction. Kids can't defend themselves against medical ID theft. If the case remains undetected, the potential "red flag" may remain on the child's record into adulthood. The worst part about cases like these is that the child is often victimized by a parent, the one person he or she should be able to trust more than any other.

Our proactive data analytics can identify such cases. We look for instances where very young children — under 5 years old — have prescriptions billed to them for tablets or capsules of high-strength prescription narcotics. These medications are too large for young children to swallow and their high potency would result in severe side effects. In a majority of cases, this tends to be a data entry error at the pharmacy that can be easily corrected. But that's not always the case.

We recently identified a case where a 7-month-old child had nine prescriptions for high doses of narcotic pain medication. The prescriptions were obtained from nine different physicians and four different pharmacies. That ruled out an inadvertent data entry error.

Eight of the prescribers were emergency room physicians — a pattern highly indicative of drug-seeking behavior. The ninth was an OB-GYN. Our investigation revealed prescriptions supposedly written by the same OB-GYN for a male as well, an unusual occurrence. When the investigator contacted the doctor, the doctor stated that she wouldn't write such high-strength narcotic prescriptions for anyone, let alone a child.

We were eventually able to identify that the doctor's prescription pad had been stolen and that the mother of the child had been using the child's identity to illegally obtain prescription drugs — either for her own use or to divert for financial reasons. Once we discovered the case, we reversed the claims, therefore correcting the child's profile and helping to prevent lasting damage to their medical record. The case is also being investigated by law enforcement.

The good news is that these cases are uncommon. The bad news is that they happen at all. Identifying and resolving cases where someone — especially a parent — is taking advantage of a child, is one of my top priorities. Helping to investigate cases like this is why I wake up every day committed to doing everything I can to ensure that no more children are victimized.

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