A “former” drug addict has posted online a step-by-step guide on how to run a narcotics scam using urgent care centers and emergency departments to get narcotics. Patrice Pash, RN, BSN, turns the tables by offering her own instructions using the blogger’s steps as a guideline.
Patrice Pash, RN, BSN, is director of operations for urgent care startup consulting firm NMN Consultants and has more than 20 years of experience working in urgent care and occupational medicine clinics. From your day-to-day strep throat cases to those off-the-wall malingerers, Pash has seen it all.
Here’s the scenario: The drug-seeker comes into your clinic with a complaint that is difficult to clinically prove or disprove, such as back pain or jaw pain. Like most urgent care visits, this is most likely the first time you have been visited by this patient, so you have no patient history to red flag your suspicions. The patient is asking for a narcotic such as Vicodin or Norco. Here are the steps the blogger recommends and how you can safeguard yourself against being scammed:
Scam Step 1: Get an appointment with a doctor, preferably one who doesn’t know you.
What to do: Have a good EMR and use it. An EMR is a vital tool in safeguarding yourself against drug fraud because you can use your EMR to thoroughly document patient encounters. Proper documentation will help you notice patterns of recent visits for nebulous complaints such as shoulder injuries, tooth aches, or jaw injuries that resulted in prescriptions for narcotics. Be sure every member of your clinic staff thoroughly documents all of their patient encounters because without documentation, these kinds of patterns will not emerge.
If you’re using a good drug-dispensing system, you can also safeguard against drug fraud by using your dispensing system to document the prescriptions you’ve written for all of your patients. This is especially helpful for practices with multiple locations. If the physicians in your urgent care practice are vigilant in their documentation, you’ll be able to see if a patient has visited other locations recently and received prescriptions for narcotics. You’ll notice red flags much more quickly while generating revenue for your clinic by prescribing in-house.
Scam Step 2: Determine what your complaint is and make yourself believe it.
What to do: Don’t let the patient experience get in the way of being a good doctor. Many scammers are good at acting like they are truly in pain, but no one wants to make the mistake of not treating a patient with a legitimate complaint. No doctor wants their patients to suffer, and no one wants to build a reputation for being a bad doctor. Because of this fear, many doctors slip into the “let’s just take care of them” mode and write up the prescription. Don’t let this fear stop you from being smart about doing proper assessments.
Remember to look for certain signs that will indicate a patient is not legitimately in pain. If you’re doing neurovascular checks, make sure the motion elicits the appropriate pain response. Watch the patient’s behavior; did a patient who is complaining of a pain level of 12 out of 10 jump onto the bed with no problem? Does the mechanism of injury match where he says the pain is? And remember: always follow your gut. If something seems amiss, it probably is. Just as you don’t want to have the reputation for being a bad doctor, you definitely don’t want your urgent care center to have the reputation for being the 7-Eleven of narcotics.
Scam Step 3: When the nurse comes in to see you, don’t give her any more than a brief and general explanation because she’s “not important.”
What to do: Foster good communication among your staff. If you foster good communication among your staff, both clinical and ancillary, this is really where you could effectively catch a scammer in the act. With Internet resources like WebMD and Wikipedia readily available, it’s easy for drug-seekers to look up a condition and learn exactly what they should complain about in order to appear legitimate. However, while most scammers are really good at keeping up the act in the clinic, they usually don’t carry through with the act in the waiting room or parking lot. Your staff is your eyes and your ears. When you foster a teamwork approach in your clinic, your staff will voluntarily notify you of a suspicious situation. Your receptionist may let you know that the patient who couldn’t bend over in the exam room bent down to get a pop out of the vending machine, or one of your nurses may tell you that the patient who couldn’t even get up onto the exam table dove right into their car when they left the clinic. A teamwork approach will make fraud of any kind difficult to execute at your clinic.
Scam Step 4: Use the time you’re waiting for the doctor to prepare answers to the doctor’s questions in a way that does not arouse suspicion.
What to do: Learn to play the game. Most scammers come prepared with tactics to deceive you, so look at the overall patient and play the game if necessary. Go through the proper assessment steps to ensure the patient is getting the treatment he needs. If a patient is going through two Vicodin every four hours, why refill it for him? If you suggest an MRI or a referral, a scammer will head straight for the door. A patient who is legitimately in that much pain will work with you to determine the cause. Above all, trust your diagnostic skills.
Scam Step 5: When you see the doctor, keep your story consistent and be sure to tell the doctor you have already tried taking over the counter pain killers.
What to do: Look for alternatives to drugs. Better living through chemistry isn’t always the answer, nor is selecting a lesser narcotic. Are there alternatives to writing that prescription? Are there other modalities you could suggest for this patient? Does your facility do physical therapy or have ties to physical therapy? Perhaps ultrasound, hot/cold therapy, E-stim, or other forms of PT can treat the patient’s pain in lieu of drugs.
Scam Step 6: Get your prescription.
What to do: Be cautious with your prescribing techniques. According to the blogger, running this scam has gotten him anywhere from 100 Norco to 15 Vicodin. Without an established relationship with the patient, it’s difficult to justify prescribing as much as100 Norco. Physicians should be very careful with their prescribing techniques to ensure they are only prescribing what is necessary to appropriately treat the patient’s chief complaint. The prescription for 15 Vicodin is more realistic in this situation, and patients with legitimate pain will be appreciative and will follow up with you if the pain does not improve. Drug-seeking patients will typically become irritated by such a small prescription and may even become argumentative, citing the excuse that they can’t get in to see their primary care doctor, so they need a larger prescription that will last until they can get an appointment.
You’ve caught a scammer. Now what?
Despite extreme vigilance, a scammer might still slip through your safeguards. If you wrote that prescription for 100 Norco, let it be a lesson to you to take a few more precautions before doling out narcotics. Otherwise, regardless of how much you prescribed, you can alert your area pharmacies not to fill the prescription for that patient. For chains, this is relatively easy since calling one Walgreens/CVS/Target/etc. hits them all. You’ll have to call the local pharmacies individually, so decide exactly to what extent you want to go to prevent this patient from filling his prescription before investing the kind of time it will take to contact the smaller local pharmacies.
If you dispensed, for example, #20 Vicodin, and the patient is already out the door, the most you can do at this point is document the incident so you’ll be red flagged if this patient returns. The patient lost out on the deal anyway because most likely they had to pay a copay for the visit and $10-$15 for the Vicodin itself, so it’s best to cut your losses. Keep in mind you should not red flag the patient as someone to turn away if he returns with a legitimate complaint, like strep throat or a broken bone. Your top priority is still to provide good healthcare.
The Journal of Urgent Care Medicine (JUCM) published a thorough article on this topic titled “Prescription Drug Abuse and the Drug-Seeking Patient” in their May 2008 issue. It’s a great resource for background information on how this problem emerged and what urgent care physicians can do to prevent patients from scamming them. Visit www.jucm.com to view an archived version. Subscriptions are free for physicians and clinical staff.