How the DEA Prioritizes and Assigns Healthcare Fraud Investigations

How the DEA Prioritizes Healthcare Fraud Investigations

The Drug Enforcement Administration (DEA) plays a key role in investigating criminal activity related to prescription drugs and controlled substances. An important part of their mission is combating healthcare fraud schemes involving doctors, pharmacists, and medical facilities.

With limited resources, the DEA must carefully prioritize which tips and cases to pursue. What factors determine how the DEA assigns healthcare fraud investigations? Here’s an overview of their process.

DEA’s Role in Healthcare Fraud Enforcement

The DEA enforces the Controlled Substances Act, which regulates the manufacture, distribution, and dispensing of legal drugs with potential for abuse. Doctors, pharmacists, drug makers and distributors must register with the DEA.

Healthcare providers who prescribe controlled substances unethically or illegally can enable drug misuse and diversion. The DEA focuses on stopping illegal prescribing and dispensing of opioids, stimulants, depressants and other controlled drugs.

How Healthcare Fraud Investigations Get Started

DEA investigations often begin with tips. Anyone can submit a tip through the DEA website or call local DEA offices. Tips can be anonymous.

Red flags for healthcare fraud include:

• Doctors prescribing high volumes of opioids or stimulants
• Patients traveling long distances to fill prescriptions
• Pharmacies ordering excessive amounts of controlled drugs
• Stolen prescription pads
• Doctors and patients colluding to sell prescription drugs

Tips from pharmacists are especially helpful, since they interact directly with patients seeking controlled drugs. The DEA also relies on data analysis to uncover patterns suggesting illegal activity.

Prioritizing Tips and Complaints

With limited agent resources, the DEA must triage incoming tips and complaints. Higher priority is given to tips that are:

• Detailed – name of facility/provider, specific suspicious activity
• Urgent – imminent public harm possible
• Credible – from reliable source like pharmacist or police
• Verifiable – contains facts DEA can independently confirm

Tips from competitors or disgruntled former employees may get lower priority if the motive seems questionable.

Focusing Investigations Where Harm Is Greatest

The DEA concentrates its healthcare fraud resources where the need is greatest. This often means prioritizing cases involving:

• Opioids – due to the epidemic of opioid abuse and overdoses
• Medicare/Medicaid – tax dollars lost to fraudulent billing
• Addiction treatment – harm to vulnerable recovering addicts
• Pill mills – doctors running prescription drug trafficking operations

Investigations into individual bad actors are balanced with cases tackling system-wide vulnerabilities. The DEA partners with other agencies that can address root causes in healthcare fraud.

Collaborating with Other Agencies

The DEA often teams up with other federal and state agencies when investigating healthcare fraud, including:

• FBI
• Department of Health and Human Services (HHS)
• Office of Inspector General (OIG)
• State medical boards
• State prescription drug monitoring programs

Collaboration maximizes impact. For example, the DEA may build a criminal case while HHS pursues administrative sanctions like revoking medical licenses.

Investigative Powers of the DEA

DEA agents have broad authority to investigate suspected illegal prescribing or dispensing of controlled substances. Tactics may include:

• Undercover operations
• Confidential informants
• Surveillance
• Inspections of pharmacies and medical offices
• Subpoenas for prescription records
• Interrogations
• Arrest and seizure warrants

Doctors and pharmacists must comply with DEA information requests during active investigations. But targets should consult with a lawyer before talking to agents or turning over documents.

Prosecuting Healthcare Fraud

After gathering evidence, the DEA may take these actions:

• Revoke DEA registration needed to handle controlled drugs
• Seek license revocation by state medical boards
• Refer cases for criminal prosecution

Charges may include drug trafficking, kickback schemes, insurance fraud, or illegal prescribing resulting in patient harm or death.

Penalties for Healthcare Fraud

Convictions can result in:

• Prison time
• Fines up to $250,000 per count
• Asset forfeiture
• Loss of DEA registration and medical license

Doctors and pharmacists often get suspended sentences with probation if they cooperate and surrender their credentials. But penalties can be harsh for large pill mill operations involving millions in fraud.

Preventing Healthcare Fraud

The DEA aims to deter healthcare fraud through education and prevention efforts. The agency publishes manuals advising doctors, pharmacists, and the drug industry on best practices for controlled substance management.

Other DEA prevention strategies include:

• Presentations at medical schools on safely prescribing opioids and identifying diversion
• Meetings with pharmacy chains and state boards about drug abuse trends
• Funding grants for prescription drug monitoring programs
• Collaborating with medical societies to develop prescribing guidelines
• Educating consumers not to share prescription medications

The DEA also maintains open lines of communication with the healthcare community. Doctors and pharmacists are encouraged to consult with DEA diversion investigators regarding suspicious activity.

While the DEA makes prevention a priority, vigorous enforcement remains key to deterring healthcare fraud. By following up on solid tips, prioritizing urgent threats, and collaborating with other agencies, the DEA takes aim at illegal prescribing.

References

Practitioner’s Manual, DEA Diversion Control Division

DEA Assessment Preparation Guide, DEA.gov

Pharmacist’s Manual, DEA Diversion Control Division

Telemedicine Prescribing, Federal Register

DEA Reasonable Accommodation Policy, DEA.gov

Practitioner’s Manual, Brandeis University