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Proprietary and Confidential Intellectual Property of
Castlestone Advisors LLC © 2015
Preventing Doctor Shopping and Opioid Abuse
A special case of Fraud, Waste and Abuse in Health Care
May 28, 2015
With the increased attention on opioid abuse many
have called for material improvements in the
Prescription Monitoring Programs (PDMPs)
Aims for PDMP’s include:
 Better Use and usability
 Real-time reporting
 Interoperability (across states)
Castlestone’s uses electronic health cards and location verification to:
 Collect information about prescriptions as they are being filled in real time
 Without this enterprising doctor shoppers can visit many pharmacists and fill many
prescriptions before PMP records catch up
 Collect information about prescriptions as they are written, also in real time
 Enterprising doctor shoppers can visit many doctors and acquire many prescriptions before
PMP records catch up.
 Stops pill mills and “rogue physicians and pharmacists” from writing/filling more
prescriptions than time and geography permit
 Use our native interstate capability to capture prescription and dispensing transactions
anywhere
 Feed any and all of this to PDMPs and state agencies
 Easy, simple card swipe, no new capital technology or software
1
Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
With Castlestone - At the Doctor’s Office the patient, the
doctor, the location, the transaction type and time are
verified and captured with a simple card swipe
2. Data on Card ID, Terminal Owner, Terminal Location
Merchant Code, Transaction Code, Time Stamp
(via credit card network infrastructure)
1. . Patient
and doctor
swipe card
Doctor keys
trans. code for
Schedule II
prescription
Castlestone runs rules against each
swipe, in real time, e.g.:
• Verifies the swipe terminal is in our
database of providers as a medical
merchant code`
• Determines if card been reported lost
or stolen or has restrictions
• Determines when/where card was
most recently swiped elsewhere
• Determines if card holder already
been issued a prescription for a Class
II or Class III drug
2
Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
Then, these data can be matched versus existing claim
and prescription records looking for duplicates,
multiples, matches
2. Data on Card ID, Terminal Owner, Terminal Location
Merchant Code, Transaction Code, Time Stamp
3. Claim Matching
• Recipient name
• HealthPlan ID
• Provider ID
• .
Health Insurer’s Analytics
(Can include PMP analytics)
Card Swipe Details
Card Number: 5424176022824317
Name: Mitchell Clark
HealthPlan ID# 6789b
Provider ID# 0077464
Swipe Terminal ID9443C3002846
(registered to Dr. Byron Black)
Date of Transaction:1/15/14
Time of Transaction 10:06:23
Claim Details
Recipient Name Mitchell Clark
Name: Mitchell Clark
HealthPlan ID# 6789b
Provider ID# 0077464
Provider Name:
Byron Black, MD
Date of Service:1/15/14
1. . Patient
and doctor
swipe card
Doctor keys
trans. code for
Schedule II
prescription
4. Notification of existing prescription stolen card,
Or other flag; can be sent directly to PMP-defined screen, etc.
3
Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
When referred, the doctor and/or the patient is
contacted before the transaction is approved
2. Data on Card ID, Terminal Owner, Terminal Location
Merchant Code, Transaction Code, Time Stamp
3. Claim Matching
• Verify terminal code
• Verify medical merchant code
• Lost or stolen card?
• Previous time and location of swipe
• Existing Rx for Class II drug?, etc.
4. Approve, Deny or Refer
5. On referral, verify before taking
action, guide to counseling , or take
other action as appropriate
Health Insurer’s Analytics
(Can include PMP analytics)
1. . Patient
and doctor
swipe card
Doctor keys
trans. code for
Schedule II
prescription
4
Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
Card Swipe Details- Doctor’s Office
Card Number: 5424176022824317
Name: Mitchell Clark
Plan ID# xxx-xx-6789
Prescriber ID# 0077464
Prescriber Name:
Richard Howard, MD
Rx Date: 1/15/14
Order Code: 11551
Claim Details
Recipient Name Mitchell Clark
Name: Mitchell Clark
HealthPlan ID# 6789b
Provider ID# 0077464
Provider Name:
Byron Black, MD
Date of Service:1/15/14
At the Pharmacy: Castlestone logs the prescription at the
time it is written and verifies for the pharmacist prior to
filling
Card Swipe Details- Pharmacist
Card Number: 5424176022824317
Name: Mitchell Clark
Plan ID# xxx-xx-6789
Supplier ID# 0088444
Supplier Name:
ABC Pharmacy, Trenton NJ
Date: 1/15/14
Order Code: 11551
• Verifies doctor visit
• Verifies prescription information
• Verifies pharmacy
• Attests that physician order came
from physician office
• Location verification of pharmacy
• Time of filling prescription
• Blocks order after fill of proper
quantity (prevent alteration)
• Blocks fill within time parameters
5
Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
Castlestone implementations comply with standards
for PDMP-EHR integration
PDMP Hub
EHR PDMP
EHR Standard:
ASAP Web Services (preferred)
HL7 v2
NCPDP SCRIPT
PDMP Standard:
PMIX-NIEM
 Delivers findings directly to physician via EHR system
 Shares all transactions with PDMP
6
Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
Cost and implementation considerations include:
 Card Creation
 Castlestone creates/activates/deactivates and manages cards based on guidelines. Plan
Sponsor existing card manufacturing contracts can be used if they are compatible
 Hardware cost for plan & providers
 NONE. Uses existing credit card terminals
 Network costs for plan & providers
 NONE. Uses the existing credit card networks from provider offices for transactions
 Systems & programming costs
 S&P is very simple data exchange of new/change/delete clients or full real time
integration
 Cost Structure
 Design and programming & card cost
 Hosting (data base & monthly hosting and management)
 Per transaction fees
7
Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
Timeframe and typical results
 Set up completely implemented in 60-75 days, depending upon client
resources
 All technical milestones (transaction capture, claim matching, file and
interface implementation) exceed goals for speed and performance
 ROI for fraud prevention is in the hundreds of percents
 Elimination and/or disabling of many false prescriptions, most notably intra-
day doctor shopping and intra-state frauds/mis-use
 Easier, more accurate access to PDMP information aiding diagnosis and
medical advice processes
 Reduction in rates of new addiction and the downstream medical, legal, social
and family costs
 Able to integrate with rehabilitation treatment plans
 Able to combine information from a similarly configured medical cannabis
enabled management process
8
Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
Castlestone’s request of Health Departments and
legislatures
1. Examine the service offering more closely in the context of the value of
real-time, intra-state, location-verified processes
 Develop hypotheses on the impact and value, tangible and intangible, to
patients, providers and the community at large
2. Determine a community/market to test the hypotheses
3. Run and refine the test, run it again, implement widely as the case
benefits become clear
9
Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
Contacting Castlestone
Doug Brockway
Business Development – New England
Castlestone Advisors LLC
(617) 834-0067
dbrockway@advancecons.com
Jeff Leston
President
Castlestone Advisors LLC
(212) 874-4390
Jeff@castlestone-llc.com
10
Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
Other uses of Castlestone you may find of interest
include:
Title Link
Fraud Prevention for Health Insurers http://slidesha.re/1pCGh98
Doctor Shopping and Prevention http://slidesha.re/1nNb9OL
CMS Pilot/Test of VisitEye http://slidesha.re/1vlGGeU
Management Tech. for Therapeutic Cannabis http://slidesha.re/1nQ5JkD
Corporate Wellness http://slidesha.re/1qQf6Fi
11
Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
Without location verification an array of fraud, waste
and abuse goes undetected
Submitted
Claims
Payments
Data Analytics
Investigation,
Compliance,
Enforcement &
Prosecution
(Large cases only)
• Services not rendered
• Misrepresented
o Date of service
o Location of service
o Provider of service
• Waiving of deductible or
copayments
• Duplicate prescriptions
• False or inappropriate
prescriptions
• False or inappropriate
fulfillment and re-fills
• Billing for non-covered
service
• Incorrect diagnosis &
bundling
• Overutilization
• Kickbacks and bribery
6.7% to 10% of Claims
Claim prep
& submit
Claim validation
& analysis
Outpatient
Services
• Clinic
• Lab
• Imaging
• Physical
Therapy
• Mental
Therapy
• Home Care
• Transport-
ation
• Pharmacy
12
Top 10 healthcare fraud schemes: http://www.acfe.com/article.aspx?id=4294976280
Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
Castlestone’s location verification, real time & other
analyses eliminate a great deal of fraud, waste & abuse
Submitted
Claims
Payments
HIGHLY FOCUSED
Investigation,
Compliance,
Enforcement &
Prosecution
6.7% to 10% of Claims
Claim prep
& submit
Claim validation
& analysis
Outpatient
Services
• Clinic
• Lab
• Imaging
• Physical
Therapy
• Mental
Therapy
• Home Care
• Transport-
ation
• Pharmacy
• Only pay claims with real, i.e. swiped,
patient and provider
• If claim data do not match swipe data,
deny or refer claim
• Now, smaller, infrequent and one-off
frauds are also stopped
Enhanced POS rules
Data Analytics
• Services not rendered
• Misrepresented
o Date of service
o Location of service
o Provider of service
• Waiving of deductible or
copayments
• Duplicate prescriptions
• False or inappropriate
prescriptions
• False or inappropriate
fulfillment and re-fills
• Billing for non-covered
service
• Incorrect diagnosis &
bundling
• Overutilization
• Kickbacks and bribery
13
Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
Outpatient process for wellness or rehabilitation:
When the participant uses a wellness service
• Authorized provider &
Location
• Service/procedure
provided matches
plan
• Time and date of
service/procedure
We now have a record of:
• A verified location for
each office visit
• The time and date it of
the visit
• Match of the
service/activity code to
the program options
If there is no card, the
provider office can register a
new card for the patient on
program portal
3) Castlestone compares
swipe with the patient’s
program
1) Provider swipes
recipient card
2) Provider enters
Service/Activity Code
• Patient ID
• Prescribing Physician ID
• Service Code
• Service Location
• Service Date
14
Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
Using electronic health cards medical marijuana
certifications are up-to-date and applied in real time
Eligibility Registration Treatment Management
Clinic
Patient
• Provider Exam
• Symptoms
• Qualifying Condition
Care Giver
• Background Check
Certification Criteria
HHS Registry
• Patients
• Caregivers
• Clinics
• Renewals and on-
going eligibilities
• Prevention of
Shopping
• Doctors
• Care Givers
• Clinics
• Inventory
• Reporting
• Inventory
• Trends
• Demographics
• Outcomes
Purchase by Patient
Purchase by Care Giver
MedicalMarijuanaProcess
Card swipes at certification and at sale record and verify
15
Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015

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Doctor Shopping and Real-time, Cross-state Prevention with Castlestone

  • 1. Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015 Preventing Doctor Shopping and Opioid Abuse A special case of Fraud, Waste and Abuse in Health Care May 28, 2015
  • 2. With the increased attention on opioid abuse many have called for material improvements in the Prescription Monitoring Programs (PDMPs) Aims for PDMP’s include:  Better Use and usability  Real-time reporting  Interoperability (across states) Castlestone’s uses electronic health cards and location verification to:  Collect information about prescriptions as they are being filled in real time  Without this enterprising doctor shoppers can visit many pharmacists and fill many prescriptions before PMP records catch up  Collect information about prescriptions as they are written, also in real time  Enterprising doctor shoppers can visit many doctors and acquire many prescriptions before PMP records catch up.  Stops pill mills and “rogue physicians and pharmacists” from writing/filling more prescriptions than time and geography permit  Use our native interstate capability to capture prescription and dispensing transactions anywhere  Feed any and all of this to PDMPs and state agencies  Easy, simple card swipe, no new capital technology or software 1 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  • 3. With Castlestone - At the Doctor’s Office the patient, the doctor, the location, the transaction type and time are verified and captured with a simple card swipe 2. Data on Card ID, Terminal Owner, Terminal Location Merchant Code, Transaction Code, Time Stamp (via credit card network infrastructure) 1. . Patient and doctor swipe card Doctor keys trans. code for Schedule II prescription Castlestone runs rules against each swipe, in real time, e.g.: • Verifies the swipe terminal is in our database of providers as a medical merchant code` • Determines if card been reported lost or stolen or has restrictions • Determines when/where card was most recently swiped elsewhere • Determines if card holder already been issued a prescription for a Class II or Class III drug 2 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  • 4. Then, these data can be matched versus existing claim and prescription records looking for duplicates, multiples, matches 2. Data on Card ID, Terminal Owner, Terminal Location Merchant Code, Transaction Code, Time Stamp 3. Claim Matching • Recipient name • HealthPlan ID • Provider ID • . Health Insurer’s Analytics (Can include PMP analytics) Card Swipe Details Card Number: 5424176022824317 Name: Mitchell Clark HealthPlan ID# 6789b Provider ID# 0077464 Swipe Terminal ID9443C3002846 (registered to Dr. Byron Black) Date of Transaction:1/15/14 Time of Transaction 10:06:23 Claim Details Recipient Name Mitchell Clark Name: Mitchell Clark HealthPlan ID# 6789b Provider ID# 0077464 Provider Name: Byron Black, MD Date of Service:1/15/14 1. . Patient and doctor swipe card Doctor keys trans. code for Schedule II prescription 4. Notification of existing prescription stolen card, Or other flag; can be sent directly to PMP-defined screen, etc. 3 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  • 5. When referred, the doctor and/or the patient is contacted before the transaction is approved 2. Data on Card ID, Terminal Owner, Terminal Location Merchant Code, Transaction Code, Time Stamp 3. Claim Matching • Verify terminal code • Verify medical merchant code • Lost or stolen card? • Previous time and location of swipe • Existing Rx for Class II drug?, etc. 4. Approve, Deny or Refer 5. On referral, verify before taking action, guide to counseling , or take other action as appropriate Health Insurer’s Analytics (Can include PMP analytics) 1. . Patient and doctor swipe card Doctor keys trans. code for Schedule II prescription 4 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  • 6. Card Swipe Details- Doctor’s Office Card Number: 5424176022824317 Name: Mitchell Clark Plan ID# xxx-xx-6789 Prescriber ID# 0077464 Prescriber Name: Richard Howard, MD Rx Date: 1/15/14 Order Code: 11551 Claim Details Recipient Name Mitchell Clark Name: Mitchell Clark HealthPlan ID# 6789b Provider ID# 0077464 Provider Name: Byron Black, MD Date of Service:1/15/14 At the Pharmacy: Castlestone logs the prescription at the time it is written and verifies for the pharmacist prior to filling Card Swipe Details- Pharmacist Card Number: 5424176022824317 Name: Mitchell Clark Plan ID# xxx-xx-6789 Supplier ID# 0088444 Supplier Name: ABC Pharmacy, Trenton NJ Date: 1/15/14 Order Code: 11551 • Verifies doctor visit • Verifies prescription information • Verifies pharmacy • Attests that physician order came from physician office • Location verification of pharmacy • Time of filling prescription • Blocks order after fill of proper quantity (prevent alteration) • Blocks fill within time parameters 5 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  • 7. Castlestone implementations comply with standards for PDMP-EHR integration PDMP Hub EHR PDMP EHR Standard: ASAP Web Services (preferred) HL7 v2 NCPDP SCRIPT PDMP Standard: PMIX-NIEM  Delivers findings directly to physician via EHR system  Shares all transactions with PDMP 6 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  • 8. Cost and implementation considerations include:  Card Creation  Castlestone creates/activates/deactivates and manages cards based on guidelines. Plan Sponsor existing card manufacturing contracts can be used if they are compatible  Hardware cost for plan & providers  NONE. Uses existing credit card terminals  Network costs for plan & providers  NONE. Uses the existing credit card networks from provider offices for transactions  Systems & programming costs  S&P is very simple data exchange of new/change/delete clients or full real time integration  Cost Structure  Design and programming & card cost  Hosting (data base & monthly hosting and management)  Per transaction fees 7 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  • 9. Timeframe and typical results  Set up completely implemented in 60-75 days, depending upon client resources  All technical milestones (transaction capture, claim matching, file and interface implementation) exceed goals for speed and performance  ROI for fraud prevention is in the hundreds of percents  Elimination and/or disabling of many false prescriptions, most notably intra- day doctor shopping and intra-state frauds/mis-use  Easier, more accurate access to PDMP information aiding diagnosis and medical advice processes  Reduction in rates of new addiction and the downstream medical, legal, social and family costs  Able to integrate with rehabilitation treatment plans  Able to combine information from a similarly configured medical cannabis enabled management process 8 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  • 10. Castlestone’s request of Health Departments and legislatures 1. Examine the service offering more closely in the context of the value of real-time, intra-state, location-verified processes  Develop hypotheses on the impact and value, tangible and intangible, to patients, providers and the community at large 2. Determine a community/market to test the hypotheses 3. Run and refine the test, run it again, implement widely as the case benefits become clear 9 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  • 11. Contacting Castlestone Doug Brockway Business Development – New England Castlestone Advisors LLC (617) 834-0067 dbrockway@advancecons.com Jeff Leston President Castlestone Advisors LLC (212) 874-4390 Jeff@castlestone-llc.com 10 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  • 12. Other uses of Castlestone you may find of interest include: Title Link Fraud Prevention for Health Insurers http://slidesha.re/1pCGh98 Doctor Shopping and Prevention http://slidesha.re/1nNb9OL CMS Pilot/Test of VisitEye http://slidesha.re/1vlGGeU Management Tech. for Therapeutic Cannabis http://slidesha.re/1nQ5JkD Corporate Wellness http://slidesha.re/1qQf6Fi 11 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  • 13. Without location verification an array of fraud, waste and abuse goes undetected Submitted Claims Payments Data Analytics Investigation, Compliance, Enforcement & Prosecution (Large cases only) • Services not rendered • Misrepresented o Date of service o Location of service o Provider of service • Waiving of deductible or copayments • Duplicate prescriptions • False or inappropriate prescriptions • False or inappropriate fulfillment and re-fills • Billing for non-covered service • Incorrect diagnosis & bundling • Overutilization • Kickbacks and bribery 6.7% to 10% of Claims Claim prep & submit Claim validation & analysis Outpatient Services • Clinic • Lab • Imaging • Physical Therapy • Mental Therapy • Home Care • Transport- ation • Pharmacy 12 Top 10 healthcare fraud schemes: http://www.acfe.com/article.aspx?id=4294976280 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  • 14. Castlestone’s location verification, real time & other analyses eliminate a great deal of fraud, waste & abuse Submitted Claims Payments HIGHLY FOCUSED Investigation, Compliance, Enforcement & Prosecution 6.7% to 10% of Claims Claim prep & submit Claim validation & analysis Outpatient Services • Clinic • Lab • Imaging • Physical Therapy • Mental Therapy • Home Care • Transport- ation • Pharmacy • Only pay claims with real, i.e. swiped, patient and provider • If claim data do not match swipe data, deny or refer claim • Now, smaller, infrequent and one-off frauds are also stopped Enhanced POS rules Data Analytics • Services not rendered • Misrepresented o Date of service o Location of service o Provider of service • Waiving of deductible or copayments • Duplicate prescriptions • False or inappropriate prescriptions • False or inappropriate fulfillment and re-fills • Billing for non-covered service • Incorrect diagnosis & bundling • Overutilization • Kickbacks and bribery 13 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  • 15. Outpatient process for wellness or rehabilitation: When the participant uses a wellness service • Authorized provider & Location • Service/procedure provided matches plan • Time and date of service/procedure We now have a record of: • A verified location for each office visit • The time and date it of the visit • Match of the service/activity code to the program options If there is no card, the provider office can register a new card for the patient on program portal 3) Castlestone compares swipe with the patient’s program 1) Provider swipes recipient card 2) Provider enters Service/Activity Code • Patient ID • Prescribing Physician ID • Service Code • Service Location • Service Date 14 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  • 16. Using electronic health cards medical marijuana certifications are up-to-date and applied in real time Eligibility Registration Treatment Management Clinic Patient • Provider Exam • Symptoms • Qualifying Condition Care Giver • Background Check Certification Criteria HHS Registry • Patients • Caregivers • Clinics • Renewals and on- going eligibilities • Prevention of Shopping • Doctors • Care Givers • Clinics • Inventory • Reporting • Inventory • Trends • Demographics • Outcomes Purchase by Patient Purchase by Care Giver MedicalMarijuanaProcess Card swipes at certification and at sale record and verify 15 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015