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Protecting your Practice

Protecting your Practice. Jill E. Lee, R.Ph. Investigator Drug Enforcement and Professional Practices Branch Office of Inspector General Kentucky Cabinet for Health and Family Services Kentucky Coalition of Nurse Practitioners/Nurse Midwives April 15, 2014. Disclosure. Jill E. Lee

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Protecting your Practice

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  1. Protecting your Practice Jill E. Lee, R.Ph. Investigator Drug Enforcement and Professional Practices Branch Office of Inspector General Kentucky Cabinet for Health and Family Services Kentucky Coalition of Nurse Practitioners/Nurse Midwives April 15, 2014

  2. Disclosure • Jill E. Lee • No relevant financial relationships. • No conflicts of interest. Cabinet for Health and Family Services

  3. Contents • Provider Shopping • The Drug Enforcement and Professional Practices Branch • How to Avoid Doctor Shoppers • Tips from DEPPB to Protect Your Practice rectinProtecting Cabinet for Health and Family Services

  4. Provider Shopping

  5. Provider Shopping Provider shopping is when controlled substances are acquired by deception. The following actions are prohibited under KRS 218A.140 when done in an attempt to obtain a controlled substance: • Knowingly misrepresenting or withholding information from a practitioner. • Providing a false name or address. • Knowingly making a false statement. • Falsely representing to be authorized to obtain controlled substances. • Presenting a prescription that was obtained in violation of the above. • Affixing a false or forged label to a controlled substance receptacle. Cabinet for Health and Family Services

  6. Typical Provider Shopping Behaviors Cabinet for Health and Family Services

  7. Typical Provider Shopping Behaviors (Cont.) Cabinet for Health and Family Services

  8. The Drug Enforcement and Professional Practices Branch(DEPPB)

  9. Drug Enforcement Branch • The Drug Enforcement and Professional Practices Branch (DEPPB) is housed within the Cabinet for Health and Family Services: • Office of Inspector General (OIG) • Division of Audits and Investigations • DEPPB Responsibilities: • Enforcement of Kentucky Controlled Substances Act (KRS 218). • Conducting drug investigations. • Licensing drug manufacturers and distributors. • Enforcement of Kentucky Food, Drug and Cosmetic Act (KRS 217). • Operation of the KASPER program. Cabinet for Health and Family Services

  10. DEPPB Investigators • Over the years DEPPB has migrated from a purely law enforcement agency to a consulting and assistance role in supporting investigations by other law enforcement agencies. • DEPPB investigators, by statute, are all pharmacists thereby giving them a unique insight into drugs, providers and dispensers. Cabinet for Health and Family Services

  11. DEPPB Investigators DEPPB Phone Number: 502-564-7985 Paula York Jill Lee Amanda Ward Carrie Gentry Laura Beth Wells Chris Johnson Duncan McCracken Cabinet for Health and Family Services

  12. Substance Use Disorder Substance use disorder is an illness that sometimes drives a patient to perform activities that are illegal. It is important to remember that the patient who is provider shopping may have an underlying illness that can be diagnosed and treated. Cabinet for Health and Family Services

  13. Practitioner Judgment Practitioners must use their best professional judgment to determine: • when to intervene with a provider shopping patient and provide treatment, or refer them to treatment • when to dismiss a patient or just not write controlled substance prescriptions for them • when to contact law enforcement to report a provider shopper Cabinet for Health and Family Services

  14. Diversion What do you do when diversion is suspected? • If you suspect an individual is involved in diverting controlled substances, we ask that you please report them to the proper law enforcement authorities. • If unsure who to contact please call the Drug Enforcement and Professional Practices Branch of the Office of the Inspector General for assistance. • (502) 564-7985 • http://www.chfs.ky.gov/os/oig/auditsinv Cabinet for Health and Family Services

  15. Diversion Reporting Provider Shoppers/Diverters • KRS 218A.280 Controlled substances – Communications with practitioner not privileged. • Information communicated to a practitioner in an effort unlawfully to procure a controlled substance, or unlawfully to procure the administration of any controlled substance, shall not be deemed a privileged communication. Cabinet for Health and Family Services

  16. Reporting Provider Shoppers/Diverters • 902 KAR 55:110 Section 10 (4) (b): In addition to the purposes authorized under KRS 218A.202(8)(e), and pursuant to KRS 218A.205(2)(a) and (6), a practitioner or pharmacist who obtains KASPER data or a report under KRS 218A.202(6)(e)1. or who in good faith believes that any person, including a patient, has violated the law in attempting to obtain a prescription for a controlled substance, may report suspected improper or illegal use of a controlled substance to law enforcement or the appropriate licensing board. Cabinet for Health and Family Services

  17. Tips from DEPPB

  18. Tips from DEPPB- Be Informed • Remain up to date with KBN rules and the Nurse Practice Act KRS 314 and Regulations 201 KAR 20 (available on KBN Web site: http://kbn.ky.gov ). • Keep well-documented patient records. • Be familiar with office personnel and their interactions with patients. Cabinet for Health and Family Services

  19. Tips from DEPPB – Doctor Shoppers How to identify doctor shoppers and avoid becoming a victim! • Use KASPER. • New patients • Before prescribing a controlled substance • Every 3 months for patients receiving a controlled substance • Be suspicious if a patient requests specific or brand name drugs. • Require photo id for patient records. Cabinet for Health and Family Services

  20. Tips from DEPPB – Doctor Shoppers • Be suspicious of vague or inconsistent patient complaints. • Be suspicious of patients coming with family members, all wanting the same medications or with the same complaint. • Is the patient carpooling to your office with other patients? • Do patients know each other? Are they possibly mingling in the parking lot after their visits? Cabinet for Health and Family Services

  21. Tips from DEPPB – Doctor Shoppers • Check patient address. Are patients driving long distances to see the prescriber? • Be wary of patients asking for frequent early prescriptions due to vacations, or new prescriptions when they should still have refills available. • Be suspicious of patients claiming lost or stolen medications. Require a police report, or if you believe them, limit them to one time. Cabinet for Health and Family Services

  22. Tips from DEPPB – Doctor Shoppers • Be suspicious of patients stating they are allergic to NSAIDs. • If a patient presents an MRI, verify it is from a legitimate facility. • Be suspicious of patients who frequently show up late in the day or on Friday afternoon (hoping you will be too busy to ask many questions or conduct a thorough examination). Cabinet for Health and Family Services

  23. Tips from DEPPB – Doctor Shoppers • Other medications we have been seeing that patients are doctor shopping/diverting: Clonidine Cyclobenzaprine Gabapentin Promethazine Seroquel Cabinet for Health and Family Services

  24. Questions to ask the patient! • Are you seeing other practitioners for this or any other reason? • When did you last see the other practitioner? • What medications were you prescribed? • What pharmacy did you use? • Request identification with photo, DOB, SSN and address. Compare the above information with the KASPER report. Cabinet for Health and Family Services

  25. Tips from DEPPB - KASPER • Humans enter all data that is submitted to KASPER. Please use rational judgment, discussions with patient and verification from dispensers to guide you. • If you think there is an error in KASPER, contact the dispenser to discuss error corrections. KASPER staff is available to help with any questions or problems you may encounter. For support, please contact the KASPER Help Desk at eKASPERhelp@ky.gov or 502-564-2703 Cabinet for Health and Family Services

  26. Tips from DEPPB – KASPER (2) Cabinet for Health and Family Services

  27. Tips from DEPPB – KASPER (3) • Never give anyone your password • Assign delegates – delegates can be assigned to more than 1 provider • Make sure KASPERs are run under your name if you are seeing patient • Use Reverse KASPER to evaluate the scripts reported dispensed under your credentials Cabinet for Health and Family Services

  28. Tips from DEPPB- Prescribing • Identify yourself on prescription • If there are 6 doctors and 4 APRN’s at your office listed on the • prescription blank, make sure you circle your name. • Clearly identify the patient • Be sure to write the patient’s full name on the prescription, including any suffixes. Include the patient address and date of birth to reduce fraudulent activity. • Spell out quantities and refills in addition to writing or circling the number on the prescription • Make copy of prescription for chart • Cancel Refills at the pharmacy if changing medication Cabinet for Health and Family Services

  29. Security Prescription Blank (902 KAR 55:105) Federal Law Requires Prescriber Name, Address and Registration (DEA#) A latent repetitive VOID at 5% in Pantone Green-if copied Void appears in pattern across entire script ¾ inch Opaque Rx Symbol 1/8in. from top, 5/16 in. from side Rx is 4 ¼ inch high and 5 ½ inch wide 6 Quantity Check-Off Boxes Thefollowing statement at bottom of blank Refill Options on Left Side in this order Prescription is void if more than one (1) prescription is written per blank Printed Watermark on Back: “Kentucky Security Prescription” Horizontal–5 lines-Helvetica style

  30. Tips from DEPPB- Rx Blanks • Order controlled substance blanks that meet state security requirements – KAR 55:105 • Store Rx pads in a secure spot – even from office staff • Do not pre-sign Rx blanks • Do not use Rx blanks pre-signed by your collaborative physician • Do not post-date prescriptions: • All written and facsimile prescriptions for controlled substances shall be dated • and signed by the practitioner on the date issued and shall bear the full name • and address of the patient, drug name, strength, dosage form, quantity • prescribed, directions for use, and the name, address and registration number • of the practitioner • Scripts for compounded controlled substances are not exempt from controlled substance laws Cabinet for Health and Family Services

  31. Tips from DEPPB - Screening • Require patient to sign drug or pain contract with the prescriber. • Consider limiting the patient to one pharmacy in the contract. • Perform random drug screens/drug counts • 201 KAR 20:057. Scope and standards of practice of advanced practice registered nurses. (8) If prescribing a controlled substance for the treatment of chronic, noncancer pain, the APRN, in addition to the requirements of this section, shall obtain a baseline drug screen or further random drug screens if the APRN:       (a) Deems a drug screen to be clinically appropriate; or       (b) Believes that it is appropriate to determine whether or not the controlled substance is being taken by the patient Cabinet for Health and Family Services

  32. Tips from DEPPB-Know the limits Jlee2014 Cabinet for Health and Family Services

  33. Sources of Confusion • Unless you are certified as a psych/mental heath APRN, you cannot write for more than a 72 hour supply of a C-II psychostimulant (ADHD meds). • Even if you are certified as a psych/mental health APRN, you cannot write for more than a 72 hour supply of any other C-II. • You cannot write Suboxone prescriptions for addiction; only physicians can be Data Waived • You cannot issue multiple prescriptions (see KRS 314.011) • Nubain and Tramadol –schedule IV in KY (not federally • scheduled) • Talwin (pentazocine), Phenobarb – schedule III in KY • (scheduled IV federally) Cabinet for Health and Family Services

  34. Sources of Confusion (Cont.) • APRN’s cannot dispense controlled substance medications- see KRS 314.011 (8) • APRN’s cannot order controlled substances to dispense in office • You can not supervise a PA-C – only physicians can supervise- see KRS 311.840 • Weight Loss Clinics/Amphetamine like substances • Can not dispense meds if doctor not in office • Must conform to standards of practice Cabinet for Health and Family Services

  35. Tips from DEPPB - Ethics • Do not write controlled substance prescriptions for YOURSELF or FAMILY • See BON Advisory Opinion on BON web site: • #37  Role of the Advanced Practice Registered Nurse in the Prescribing of Medications to Self and/or Family • Writing controlled substance prescriptions for friends, co-workers, or employees • See 201 KAR 20:057 for all requirements • Chart with a KASPER in it, medical history, treatment plan, diagnostic examinations, documented consent, etc.. Cabinet for Health and Family Services

  36. Tips from DEPPB- Pain Facility • KRS 218A.175- Pain Management Facilities • Physician ownership required • Subspecialty/certification required • Can not be a cash only business • Oversight Requirement • Definition of a Pain Management Facility • A facility where majority of patients provided controlled substances for pain AND • Primary practice component is treatment of pain • Facility advertises any type of pain management services • APRNs CANNOT OWN PAIN FACILITIES Cabinet for Health and Family Services

  37. The Take-Away Messages • The Drug Enforcement and Professional Practices Branch is available to support your practice. • Use KASPER regularly. • Please remain alert and be careful! Cabinet for Health and Family Services

  38. QUESTIONS? Jill Lee 502-564-2815 ext. 3356 JillE.Lee@ky.gov

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