CMS and OMIG Provide Guidance on Combating Opioid Epidemic

February 15, 2017 | Health Services

The Healthcare Fraud Prevention Partnership (“HFPP”), in conjunction with the U.S. Department of Health and Human Services and the Centers for Medicare and Medicaid Services (“CMS”), has recently issued a White Paper that outlines recommended actions to reduce opioid misuse and opioid-use disorders (“OUDs”) in the United States. It has been estimated that prescription opioid misuse and OUDs have cost the U.S. economy over $78 million in 2013. The rate of opioid overdoses has also drastically increased. In addition, opioid prescriptions are often fraudulently obtained and resold on the black market. HFPP hopes to combat this national epidemic by encouraging health care payors and other stakeholders to follow certain steps that can reduce fraud, waste and abuse correlated with opioid misuse, while ensuring that opioids remain accessible when medically necessary to reduce pain and suffering caused by underlying conditions.

HFPP recognizes that payors maintain unique relationships with patients, providers and other stakeholders in the health care industry and, therefore, are best suited for combatting the opioid epidemic through public outreach and revisions to their reimbursement and prescription guidelines. HFPP established three general principles for reducing opioid misuse: (i) disseminating resources, policies and procedures regarding opioid treatment to help providers and patients select care that maximizes health outcomes; (ii) identifying and mitigating fraud, waste and abuse associated with opioid prescriptions; and (iii) researching ways to effectively reduce opioid misuse and OUDs. In accordance with these principles, HFPP recommends that payors engage in the following five steps:

  1. Share and analyze data to identify suspicious opioid prescription trends and other fraudulent, wasteful and abusive practices.
    Data that is accessible to payors can help identify patients at a high risk for opioid misuse and establish a corrective action plan that can both improve patient health and reduce non-medical use of prescription opioids and correlated fraud, waste and abuse.
  2. Train health care providers on the Centers for Disease Control and Prevention (“CDC”) guidelines for prescribing opioids for chronic pain.
    The CDC guidelines can help providers determine when opioid treatment is appropriate, how to determine the dosage, duration and discontinuation of the opioid prescription, and how to address risks and other harmful side effects of opioid use.
  3. Encourage use of medication-assisted treatment to address opioid misuse and OUDs.
    Research has found that opioid detoxification and relapse prevention can be more effective when certain medications (specifically, methadone, buprenorphine and naltrexone) are used in conjunction with behavioral therapy. HFPP believes that payors can effectively promote the use of such medications by educating providers and establishing more favorable reimbursement policies.
  4. Promote availability of naloxone.
    Naloxone can immediately reverse the effects of an opioid overdose and prevent death, without any harmful side effects. It is approved by the U.S. Food and Drug Administration and can be easily administered by anyone, such as a friend or family member in emergency situations. HFPP encourages payors and providers to make naloxone more available to patients, especially those at a high risk for opioid misuse.
  5. Identify and disseminate best practices for opioid treatment.
    HFPP believes that payors are in the best position to combat the opioid epidemic because they can work collaboratively to establish best practice guidelines with regards to opioid use and misuse. Through a combined effort, payors can also distribute such guidelines across a wide range of the health care industry, including patients, providers, health systems and other key stakeholders.

Following the release of HFPP’s White Paper, the New York Office of the Medicaid Inspector General (“OMIG”) also released a statement encouraging New York payors and providers to follow the five action items identified by HFPP. Dennis Rosen, the Medicaid Inspector General stated: “New York is a nationally recognized leader in the fight against opioid fraud and abuse, and continues to take steps to aggressively combat the epidemic’s devastating effects on families and communities. With the approaches, action steps and strategies described in the White Paper by [HFPP], health care payers across the nation can achieve significant results in fighting fraud and helping those with opioid abuse and addiction.” To review the entire White Paper by HFPP, see

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