MDs refuse

CLASSIC

*
PR
Psych referral Low impact MVA Disability
I

MEDICAL Fraud

Gap Case

Case Types
Claims inj @ work
Chronic Disease Derivative

Months pass, GAP widens

finds lawyer, brings suit.

A

V
E-Problem: emotional

GAP Cases: alleged
claims work-related;

Pre-Existing DX:
problem presenting as

injury occurred

wks/months ago, now

<">
records of DX a RX

discovery > medical

claiming disability is

<
Solution

>

a Rational Problem, needs Emotional

work-related

for pre-existing DX. A Manager 1
Your DBA Cases: claimant -WC-

:

<i>
has a "doing business
related
case

Manager 2

YDYB Cases:

Solutions offered are

Male YDYB and

never any good,
as" license on file at
the courthouse.

Y2K Syndrome

nothing helps, stays off work long time.
I

sss

2nd job
- pays cash

Original
JOB

"Y2K Syndrome:" per
Hunting while Sports while
off work

types

2nd JOB

year, has 2,000 or
off work

more symptoms,

Female, working

always changing,

never resolved

or at home

I
"Deer Slayer" Pick-up game

I

^-addnl coSt—^
Tests

yrf Hospital
A
addnl coSt

I
"Hurt@Work:" non

Ins Co

RX Diversion:

St 5-dnlC°St aJLt
"Dr. YES" lets them

Pays RX

occupational injury,

I
and claims it happend
on the job

employee is getting RX filled and paid for

O

but comes to work

have whatever they
want, however long

Generalists &

Specialists
they want it.

pt
Fee-for-service

addnl co$tAdditional WON'T CONFRONT PATIENTS "DX & RX"

Ins Co pays for

restocked RX

by insurance but selling it on the street.

addni coSt
nsured employee
Dealer 1 Gives RX to uninsured relative

P.T. & Chiropractic (Pt/DC conspiracy)

i\<
Home

|gn—1|
"Bed rest" Other

MDor

Prescription Drug Diversion (DEA) RX to Pharmacy
. SS to "patient"

Pharm D

workshop

business

/

Uninsured family member

Sports

FID&A: Forensic Intelligence Display & Analysis, Inc. (757) 721-3210 TollFree: 877-742-3381 R. Easton, MD. Member: lALEIA & IACA Created with i2, Inc. Analyst's Notebook

Medical Fraud Type: RX Drug Diversion
Reference: the "Classic Medical Fraud Types" posted on SCRIBD (lower left-hand corner of graphic). Drug Diversion, sometimes for illegal sale to others, sometimes for personal use. It was late in the evening after what had been a long, complicated day on call in Intensive Care. As I came out of the Unit, I was standing face-to-face with a local, muscular police officer, roughly 50 pounds heavier and 4 inches taller than me, armed with a shiny, black, 9 mm sidearm. If his words had been hollow-pointed bullets, they would have put both my eyes out. Without an introduction or "Hello" he fired away: "Why did you let my sister die?" My classic image of the situation where they say your life flashes before your eyes is one in which a person is falling from a tall building or the aircraft they are trapped in seems to be plummeting toward the earth waaaay too fast. I, on the other hand, saw my first 30 years flashing by while standing flat-footed on the solid concrete hospital floor. I knew exactly who he was talking about: his 24-year-old sister, but I was almost speechless. My mind was spinning and the only thing that was coming to mind was a warning to myself that I would not fare well if I became defensive. So, I became burning hot, tachycardic and almost short-of-breath on the inside, but hoped my fake demeanor was coming across as calm, cool, collected and in control … (what a lovely self-deception). The cop’s sister, Taylor Henderson, had been a nurse at our hospital and it was well-known that her obesity was a great concern to her. The hospital dietician had helped her get her calorie intake under control, more or less. But she was fighting the same “driven-to-eat-and-I-don’t-know-why” demon that grabs all of us at one time or another. According to the scales in the examining room, the demon was winning the battle. My first comment to Officer Henderson was: “I understand you are very, very upset about her completely unexpected illness and death, but you should know we are all upset , too … and completely in the dark about her diagnosis. At 24-years old, her acute onset of what she was calling “the flu,” followed by her rapid down-hill course, has us all a bit confused.“ Putting us all in the same boat, not knowing what happened to cause her rapid demise from healthy and happy to comatose and unrecoverable seemed to calm him down a little bit. I asked if he knew anything about her illness, any medication she had been taking or any recent change in her behavior or psychiatric condition that he was aware of. All he could offer was that the pills she had been taking seemed to be helping her lose weight. They also seemed to make her mood go from happily over-active to something unusual for her: sleeping up to 12-hours at a time. The family attributed the swing from energetic to hyper-somnolent to being busy with lots of work during the day and being understandably tired at night. To me it sounded like something more going on. One of the most helpful colleagues in town was the pharmacist who served the community from the mall across the street from the hospital. Most of the medical staff, nurses and employees all had him fill their prescriptions because his store was so convenient and he gave them personal service. If you called in from work at the hospital (and had a written prescription in hand), he would fill it for you, and deliver it to the floor where you were working, pick up the written ‘script and your payment, saving everyone the trouble of coming to the store and standing in line with the small crowd that would almost surely be in line in front of you. In addition to being one of the two superbly knowledgeable pharmacists in town, he was born and raised there, grew up with all 15,000 local citizens and had a high-speed connection to the town and county

grapevine that was invaluable to those of us who were relative newcomers (that means you arrived in town anything less than 10 years ago). He made truth out of the old adage that people read the local newspaper, not to find out the news (because they already know the news), but to find out who is getting caught doing what we all knew they were up to. The combination drug that he told me about has been banned since this all happened. It was called Eskatrol (™SKF Pharmaceuticals, which isn’t even SKF any more). Eskatrol was an amphetamine weight loss (dextroamphetamine) agent which was removed by the Food and Drug Administration in 1981 after its manufacturer, SmithKline & French, was unable to prove the drug's effectiveness. At the time it was among the 200 most widely prescribed drugs in the United States. Eskatrol contained dextroamphetamine sulfate and prochlorperazine (a dopamine (D2) receptor antagonist that belongs to the phenothiazine class of antipsychotic agents that are used for the antiemetic treatment of nausea and vertigo). In the case of Eskatrol, the prochlorperazine was supposed to counteract the anxiety and hyperactivity induced by the amphetamine. (Parenthetically: Prochlorperazine in excess dose can cause a life-threatening condition called neuroleptic malignant syndrome (NMS). Some symptoms of NMS include: high fever, stiff muscles, confusion, irregular pulse or blood pressure, a fast heart rate (tachycardia), sweating, and arrhythmias (irregular heart rhythms), sometimes related to sudden death. Finally, complicating the situation was the fact that Eskatrol was created as a time-release capsule, approved by the FDA for only short periods of time, under the control of the prescribing physician and at a dosage of one capsule per day (every 24-hours only) for appetite control during the waking hours. The pharmacist knew only of one doctor in town who was prescribing Eskatrol for Taylor (the nurse) and she was getting in filled at his pharmacy once a month (30 capsules) as prescribed. So, his initial reaction was that he had no cause to question Eskatrol as related to her death, in spite of the known amphetamine and prochlorperazine potential cardiac side-effects. However, he volunteered to broach the subject (with all due patient confidentiality) at the county-wide pharmacists monthly meeting on the coming weekend. At that point we had an obese patient, taking what seemed like a properly prescribed dose of appetite suppression medication, who got "the flu" and stayed away from work for 3-5 days, then became acutely ill and showed up in the Emergency Room on a Sunday night, with fulminant hepatitis (“acute yellow atrophy”), and was dead by Friday evening. All I could tell her brother at that time was, the “flu” should not have killed her, the hepatitis was the type that was known to be lethal, but we had no idea from whom she caught the virus and the terminal event, a Grand Mal seizure had nothing to do with hepatitis (or the flu) and she had no family or personal medical history of epilepsy or other seizure disorder. He had questions. We had questions. The autopsy only raised questions. No one had any answers. But the answers were about to roll in. On the day we found that the post was unrevealing, a call from the pharmacist who told us when Taylor’s obituary was published, a pharmacist-friend told him that he also knew she was taking Eskatrol, long-acting capsules, but she was getting them from a pharmacy across the state line in Missouri. When we heard that other pharmacies (and, by deduction, other physicians, in an adjoining state) were involved I called the KBI (Kansas Bureau of Investigation, Narcotics Division). The KBI canvassed pharmacists over four-state area and found a doctor-pharmacy pair (MD-RX pair) in each state from whom she was getting duplicate refills of Eskatrol on a weekly basis. She would go from her first doctor-pharmacy pair (MD-RX pair) in our town, who gave her a 30-day supply, to her second MD-RX pair in neighboring Missouri only seven days later and get a second 30-day supply. The next stop in the circuit would be to her third MD-RX pair in Arkansas the next week, for a third 30-day supply. A week later she would be in the office of her fourth MD-RX pair in Oklahoma getting the final 30-day supply from the circuit of MD-RX pairs. The following week, she would start to ride the weekly circuit from state-tostate again. From each MD-RX pair the KBI determined that she was getting her “normal, prescribed” 30day supply, but on a weekly (not monthly) basis. And there was never any reason for any of the four MDRX pairs to suspect anything was amiss. She had devised a system to obtain four times the amount of medication that she should have had on hand. By the fourth MD-RX pair visit she would have been in

possession of 120 Eskatrol. However, when evidence technicians searched her residence they found only a minimum number of capsules … concluding that she had taken (estimated) four (12-hour / 24-hour) capsules a day for a prolonged period of time. A lethal dose by anyone’s standards. Whether Taylor actually had influenza, or just the flu-like symptoms caused by the drugs, combined with chemical or viral hepatitis, we never pinned down to our satisfaction. We do know that the dosage she was taking was unequivocally in the overdose range. We also know that the level of prochlorperazine, on top of the irritability caused by an excess dose of long-acting amphetamine, could have precipitated a cardiac arrhythmia or arrest that stopped the blood supply to her brain and caused the seizure. It was a sad example of a unique case of prescription medication abuse, originally taken for simple weight loss, that led to a lethal ending. Taylor’s brother eventually came to my office (without his 9mm) and discussed Taylor’s case. We agreed that neither of us was satisfied with the outcome. But there were circumstances that neither he nor the family nor any of us at the hospital understood before her death … and even if we had known at that late stage, we all understood that there was probably nothing that could have been done. Epilog: Thanks to the KBI for uncovering the extent of the behavior, and to disseminating the scheme to the practicing pharmacy and medical communities to raise professional awareness. The lesson learned: what we see on any day in practice is only one moment in time, one slice of someone’s life, one piece of every puzzle that is assuredly only a small part of a person’s whole life’s activities. “Just a patient coming in to get a standard, one-month, 30-capsule prescription refill.”

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