The Next Step in the Opioid Epidemic: Protecting Government-Sponsored Health Plans from Un-Registered Providers

The misuse and abuse of opioids continues to be an epidemic in this country. As efforts are made to identify and prevent healthcare providers who may be contributing to this issue, more and more providers are voluntarily surrendering their Drug Enforcement Agency (DEA) registration number. A DEA number is needed to legally prescribe controlled substances, such as opioids.

It is important for plan sponsors to know when this occurs so they no longer process claims for controlled substances from those providers. To assist with this effort, earlier this year, the Centers for Medicare and Medicaid Services (CMS) issued several memos to announce when providers surrendered their DEA registration numbers.

CMS has asked plans how they responded to the memos on DEA number surrenders. To support you in giving your feedback, following are the questions asked by CMS along with Elixir’s responses:

1. Does the plan implement a point-of-sale prescriber edit to prevent new prescription claims from processing when CMS releases DEA registration number surrender/suspension/termination memos?

Elixir locates the affected prescriber in our claims system by using the National Provider Identifier (NPI) and DEA numbers provided and applies an expiration date to the DEA number using the voluntary surrender date in the letter. This prevents controlled substances from being processed for this prescriber, as of the surrender date.

2. Does the plan have a process that identifies impacted enrollees?

Yes, Elixir runs a utilization report that:

• Identifies members who have utilized the prescriber in the past 120 days
• Identifies any controlled substance claims processed after the surrender date
• Is provided to the client if there are any impacted members

3. Does this process include a continuity of care plan that identifies alternate network prescribers?

If any members are impacted, the plan sponsor will ensure that the member can obtain any remaining refills by working with the member to find another prescriber.

4. What type of proactive outreach communication is conducted when an impacted enrollee is identified?

If any members are impacted, the plan sponsor will prepare a communication for affected members. Your designated Elixir Compliance Officer can help draft this member letter.

Following this process, Elixir is able to protect both our clients and their members from potential opioid fraud, waste or abuse. Fortunately, none of Elixir’s clients have been impacted, but if there are any affected plans in the future, Elixir will continue to follow this process and communicate enrollee utilization to each impacted plan and be ready to assist with any member communications necessary. Plan sponsors should also develop internal processes in the event that there are future DEA registration surrenders by providers with utilization among your plan’s membership. Together, we can help in the fight against opioid misuse and abuse.