System and method for detecting drug fraud and abuse

• US 8,768,724 B2
• Filed: 04/27/2011
• Issued: 07/01/2014
• Est. Priority Date: 04/27/2010
• Status: Active Grant

• Current Assignee: The Travelers Indemnity Company (The Travelers Cos., Inc.)
• Original Assignee: The Travelers Indemnity Company (The Travelers Cos., Inc.)
• Inventors: Whiddon, Roger, Andros, Aneta, Wasik, Jeff, Sadak, Michelle
• Primary Examiner(s): Najarian, Lena
• Assistant Examiner(s): SEOH, MINNAH L
• Application Number:
  US13/095,145
• Publication Number:
  US 20110288886A1
• Time in Patent Office: 1,161 Days
• Field of Search: 705 2- 3
• US Class Current: 705/2
• CPC Class Codes: G16H 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients
• CPC Class Codes: G16H 50/70 for mining of medical data, e.g. analysing previous cases of other patients
• CPC Class Codes: G16H 70/40 relating to drugs, e.g. their side effects or intended usage
• CPC Class Codes: G16H 80/00 ICT specially adapted for facilitating communication between medical practitioners or patients, e.g. for collaborative diagnosis, therapy or health monitoring
• CPC Class Codes: G16Z 99/00 Subject matter not provided for in other main groups of this subclass

Abstract

A system and method for detecting improper drug use utilizes the morphine equivalency of a drug regimen of a patient having an injury to compare the morphine equivalency of the drug regimen of the patient to that of a peer group having the same diagnosis. The comparison may be conducted based on the aggregate morphine equivalency for respective periods of time following the injury or the initial treatment and based on the rate of change in the morphine equivalency for that or another period of time. Based on the results of the comparison, potential instances of drug fraud and/or drug abuse are identified and an alert is generated, and appropriate action is taken, where needed.

Claims

1. A computer-implemented method for detecting an improper drug use, comprising:

determining, by at least one processing device, morphine equivalency data for each drug of a plurality of drugs of a drug regimen of a patient, and for each time period of a plurality of time periods;

determining, by the at least one processing device, a total morphine equivalency for the drug regimen for each time period of the plurality of time periods, wherein the total morphine equivalency for the drug regimen for each time period comprises a sum of the morphine equivalency data for each drug of the plurality of drugs of the drug regimen of the patient for each respective time period;

identifying, by the at least one processing device, a possible instance of the improper drug use associated with the drug regimen based on the morphine equivalency data, using the at least one processor, wherein the identifying comprises determining that the total morphine equivalency for the drug regimen for at least one of the time periods of the plurality of time periods is outside of an expected range compared to a total morphine equivalency for a comparable time period of a peer group associated with the drug regimen;

generating, by the at least one processing device, an alert for the possible instance of the improper drug use; and

causing, by the at least one processing device, an outputting of an indication of the alert.

2. The method of claim 1, wherein the improper drug use comprises at least one of a drug fraud and a drug abuse.

3. The method of claim 1, wherein the peer group associated with the drug regimen comprises one or more of a peer group of doctors and a peer group of pharmacies.

4. The method of claim 1, wherein the peer group associated with the drug regimen comprises a peer group of patients having at least one of (i) the same injury as the patient, (ii) the same disease classification code as the patient, and (iii) the same partial disease classification code as the patient.

5. The method of claim 1, further comprising displaying at least a portion of the total morphine equivalency on at least one computer display.

6. The method of claim 5, further comprising displaying a plot of the total morphine equivalency over the plurality of time periods.

7. The method of claim 1, further comprising transmitting the alert to at least one of an insurance company entity, a doctor, a pharmacy, and an authority.

8. The method of claim 3, wherein the peer group associated with the drug regimen comprises a peer group of doctors, and the peer group of doctors comprises one or more of (i) doctors having a similar specialty to a doctor associated with the drug regimen and (ii) doctors that have treated patients similar to the patient associated with the drug regimen.

9. The method of claim 1, further comprising determining a treatment plan for the patient based on the total morphine equivalency.

10. The method of claim 1, further comprising causing a display of a comparison of the total morphine equivalency for the drug regimen of the patient to the total morphine equivalency of the peer group associated with the drug regimen on a computer display.

11. The method of claim 1, wherein the morphine equivalency data comprises rate of change data for a predetermined period of time.

12. The method of claim 3, wherein the peer group associated with the drug regimen comprises a peer group of pharmacies, and the peer group of pharmacies comprises pharmacies that have fulfilled a similar volume of prescriptions as a pharmacy associated with a prescription of the drug regimen to the patient.

13. The method of claim 1, wherein the morphine equivalency data comprises duration of use data.

14. A system, comprising:

a processing device; and

a memory device in communication with the processing device, the memory device storing instructions that when executed by the processing device result in;

determining morphine equivalency data for each drug of a plurality of drugs of a drug regimen of a patient, and for each time period of a plurality of time periods;

determining a total morphine equivalency for the drug regimen for each time period of the plurality of time periods, wherein the total morphine equivalency for the drug regimen for each time period comprises a sum of the morphine equivalency data for each drug of the plurality of drugs of the drug regimen of the patient for each respective time period;

identifying a possible instance of the improper drug use associated with the drug regimen based on the morphine equivalency data, wherein the identifying comprises determining that the total morphine equivalency for the drug regimen for at least one of the time periods of the plurality of time periods is outside of an expected range compared to a total morphine equivalency for a comparable time period of a peer group associated with the drug regimen;

generating an alert for the possible instance of the improper drug use; and

causing an outputting of an indication of the alert.

15. The system of claim 14, wherein the improper drug use comprises at least one of a drug fraud and a drug abuse.

16. The system of claim 14, wherein the peer group associated with the drug regimen comprises one or more of a peer group of doctors and a peer group of pharmacies.

17. The system of claim 16, wherein the peer group associated with the drug regimen comprises a peer group of doctors, and the peer group of doctors comprises one or more of (i) doctors having a similar specialty to a doctor associated with the drug regimen and (ii) doctors that have treated patients similar to the patient associated with the drug regimen.

18. The system of claim 16, wherein the peer group associated with the drug regimen comprises a peer group of pharmacies, and the peer group of pharmacies comprises pharmacies that have fulfilled a similar volume of prescriptions as a pharmacy associated with a prescription of the drug regimen to the patient.

19. The system of claim 14, wherein the peer group associated with the drug regimen comprises a peer group of patients having at least one of (i) the same injury as the patient, (ii) the same disease classification code as the patient, and (iii) the same partial disease classification code as the patient.

20. The system of claim 14, wherein the instructions, when executed by the processing device, further result in:

transmitting the alert to at least one of an insurance company entity, a doctor, a pharmacy, and an authority.

21. The system of claim 14, wherein the instructions, when executed by the processing device, further result in:

determining a treatment plan for the patient based on the total morphine equivalency.

22. The system of claim 14, wherein the morphine equivalency data comprises rate of change data for a predetermined period of time.

23. A non-transitory computer-readable medium storing instructions that when executed by a processing device result in:

determining morphine equivalency data for each drug of a plurality of drugs of a drug regimen of a patient, and for each time period of a plurality of time periods;

determining a total morphine equivalency for the drug regimen for each time period of the plurality of time periods, wherein the total morphine equivalency for the drug regimen for each time period comprises a sum of the morphine equivalency data for each drug of the plurality of drugs of the drug regimen of the patient for each respective time period;

identifying a possible instance of the improper drug use associated with the drug regimen based on the morphine equivalency data, wherein the identifying comprises determining that the total morphine equivalency for the drug regimen for at least one of the time periods of the plurality of time periods is outside of an expected range compared to a total morphine equivalency for a comparable time period of a peer group associated with the drug regimen;

generating an alert for the possible instance of the improper drug use; and

causing an outputting of an indication of the alert.

24. The non-transitory computer-readable medium of claim 23, wherein the improper drug use comprises at least one of a drug fraud and a drug abuse.

25. The non-transitory computer-readable medium of claim 23, wherein the peer group associated with the drug regimen comprises one or more of a peer group of doctors and a peer group of pharmacies.

26. The non-transitory computer-readable medium of claim 25, wherein the peer group associated with the drug regimen comprises a peer group of doctors, and the peer group of doctors comprises one or more of (i) doctors having a similar specialty to a doctor associated with the drug regimen and (ii) doctors that have treated patients similar to the patient associated with the drug regimen.

27. The non-transitory computer-readable medium of claim 25, wherein the peer group associated with the drug regimen comprises a peer group of pharmacies, and the peer group of pharmacies comprises pharmacies that have fulfilled a similar volume of prescriptions as a pharmacy associated with a prescription of the drug regimen to the patient.

28. The non-transitory computer-readable medium of claim 23, wherein the peer group associated with the drug regimen comprises a peer group of patients having at least one of (i) the same injury as the patient, (ii) the same disease classification code as the patient, and (iii) the same partial disease classification code as the patient.

29. The non-transitory computer-readable medium of claim 23, wherein the instructions, when executed by the processing device, further result in:

transmitting the alert to at least one of an insurance company entity, a doctor, a pharmacy, and an authority.

30. The non-transitory computer-readable medium of claim 23, wherein the instructions, when executed by the processing device, further result in:

determining a treatment plan for the patient based on the total morphine equivalency.

31. The non-transitory computer-readable medium of claim 23, wherein the morphine equivalency data comprises rate of change data for a predetermined period of time.