The Dog Ate My Homework: A Guide to Avoiding Relapse and Maintaining Adherence

Payers are becoming more sophisticated and less risk-tolerant in their approach to performing opioid prescribing surveillance and often reach out to prescriber practices when they perceive excessive risk. Providers are encouraged to make changes to increase safety or face costly remediation or network termination, and they often express confusion regarding data or metrics used to make these decisions. We will give providers perspective on the methodology that many prominent payers use to evaluate a provider's practice. It is a complex process employed by payers to leverage available medical and pharmacy claims data and turn raw data into measurable metrics to document clinical outcomes. By itself, claims data tell only of patterns and basic prescribing practices; however, when combined with medical review of claims data and patient charts, the data often forms the basis for punitive action against prescribers from claims denials, network exclusion, licensing board actions, and DEA involvement. It is important to understand the importance of writing your own script to guide investigators and your legal counsel through your medical decision-making process. Individual metrics will be defined and explained to raise awareness for providers of areas where increased vigilance will spare their practice from additional scrutiny or adverse action.