Drug Seekers have always been one the biggest challenges to physicians of all specialties. Plastic Surgeons have never been immune to this demographic of patient, but the current environment of electronic prescribing and monitoring has placed new challenges for narcotic abusers and dealers. The State of Alabama Medical Board of Examiners has implemented tools to help physicians verify and monitor patient prescriptions via an on-line portal. Along with this helpful system, the medical board appears to be on a mission of intimidation to those physicians who might be classified has high prescribers. The last few newsletters published by the Alabama medical board contain educational articles regarding this practice and how to prevent being a target by these “patients.” However, the tools suggested are not enough to protect the physician from new tactics by desperate drug seekers.
Since the first of this year, Plastic Surgeons have noticed an increase of new patients that fit this persona. Since their usual “sources” aka primary care physicians, orthopedics, internal medicine and pain management clinics are under the gun by the medical board to help reduce narcotic abuse, addicts and dealers are choosing new targets. Plastic Surgeons long have a history of highly individualized care for these elective procedures that include more personal access to the surgeon and/or staff. Allow me to first outline a some examples experienced by our office and other physicians:
(1) New Patient presents for cosmetic surgery consultation. The patient schedules surgery and a pre-operative appointment at which time the patient will sign necessary paperwork, receive pre-operative instructions including prescriptions required for day of procedure. The patient pays by check. The check is returned for insufficient funds. The procedure is cancelled. Patient is contacted and claims to have changed their mind regarding the procedure. The prescription is not returned as requested.
(2) Patient has liposuction procedure. Two days following procedure, patient’s caretaker calls to request a refill of pain pills. The refill is denied pending patient’s appointment the following day. Caretaker attempts to bribe the nurse into calling in the refill.
(3) A new patient appears for consultation. After being placed in exam room, office staff can over-hear the cabinet doors opening and closing in said exam room. When they open the door, the patient is sitting in the chair. Only then do they realize why the patient is carrying an oversized handbag that appears to be empty. Apparently bottles of alcohol, peroxide, and ointment were not on their wish list. Patient never signs up for any procedure.
(4) A new patient arrives early for their consultation. Appearing frustrated, the new patient informs receptionist their cell phone is not operational and they request to borrow an office phone. The receptionist offers her mobile phone charger instead. Patient refuses the assistance of the charger and still insists on needing to use a “land-line” phone.
(5) A tummy tuck patient, who had requested multiple narcotic refills following surgery shows for a scheduled post-operative appointment. Having already been cut-off of narcotic refills and Tylenol recommended, the patient shows with her husband. While in the exam room, the husband becomes aggressive with the surgeon demanding a full script pad of signed blanks. The altercation became violent when surgeon refused. Office staff dialed 911. Suspects fled the scene before police arrived but not after threatening bodily harm to the doctor and his staff.
(6) A primary care physician is threatened by a drug seeking patient during a routine office visit. Patient threatens a multitude of threats including bodily harm, law suit, sexual harassment claim, and filing formal complaints with governing hospital and state medical board. He refuses. Patient follows thru with complaints with the hospital and medical board. The physician was forced to defend himself in a “she said he said” situation.
(7) A primary care physician is contacted by a local pharmacist requesting prescription verification. The pharmacist had been presented with narcotic script with a very high pill count. The prescription was a fraud and the pharmacist destroyed the script. Upon further investigation, the physician discovered numerous prescriptions had been written using a counterfeit prescription pad, forging his signature and even using his correct medical license number and DEA number.
(8) Several years ago, Plastic Surgeon’s wife (me) went to fill a prescription of Valium written for her by her husband just prior to having to put-down their beloved 16 year old dog. At the pharmacy, the pharmacist questioned the prescription and stated he had just filled a prescription earlier that day in the same name by the same doctor for narcotics. I demanded to see the prescription and even requested he contact my husband. I gave him my driver’s license to verify I was who I claimed to be and he gave me a description of the person who came earlier with the narcotic prescription. The description closely resembled an employee and the pharmacist refused to give me a copy of the prescription presented. He also refused to speak with my husband whose signature had been forged. In my investigation, I discovered a flaw in our practice software that allowed users to print prescriptions then delete the records. The software was fixed and the employee eventually fired after obtaining further proof of misconduct.
As you can see, physicians are at risk and drug-seeking patients have very little fear. Stories such as these are never ending. Physicians are now forced to protect their credentials from all angles. Documentation in medical records is at a whole new level when dealing with drug seekers, that’s if you have a medical record.
First of all, let’s examine the ways these drug seekers obtain your correct medical license numbers and DEA number: internet. The first guilty party is Angie’s List. Physicians do not create their own profiles on their service, but are allowed to monitor their profiles and can request to correct the information. The physician must email the web site administrators to request removal of their sensitive license numbers. Physicians of all specialties should hire an in-house web site administrator to not only handle your sensitive web site material, but now to help monitor the web for abuses of your protected license numbers and reputation. Out sourcing this position is not advised.
Second, remove any and all office land-lines from unprotected areas of your office. The “my cell phone died” trick is a ruse to use your phone to call a pharmacy. Pharmacies often use caller-ID as their prescription verification methods. Otherwise, anyone from any phone number could call in a prescription claiming to be your nurse, especially if they already have your license numbers from the internet or from a previously written prescription. Even if you only use electronic prescriptions, not all pharmacists will know this is your office policy.
Third, create a new document for your office employee manual. If a chapter regarding prescription fraud is not already present, it’s time to revise. Medical staffs are often targeted by drug-seekers, often buddying-up to them offering bribes or playing a pity story. It’s time for all physicians to have a camp-fire meeting about this sensitive subject making very clear they are all at risk should only one cross this line. Make sure your employees understand it’s your medical license at stake, which is your career and all of their jobs. When hiring new employees, verifying employment history is imperative. Also, if an employment history of “doctor-hopping” is present, skip and move on to the next candidate.
Assign only one staff member responsible for handling prescriptions: calling in refills, access to the old-school paper prescriptions pads, and password protected access in the computer system for electronic prescriptions and printing. Otherwise, this duty will be all yours. Request this person to also create a daily prescription log by the end of every day to be placed on your desk.
For the threatening situations mentioned among the examples, there are few suggestions to help avoid or to defend yourself. The internal medicine physician now carries a small recorder in his pocket at every patient encounter. In most states, this practice is legal as long as one of the parties involved is aware of the recording. Many commercial phone systems also have a “record” button. If your practice software will allow for audio or visual recording files, then consider this protection as part of your patient’s medical record. Otherwise, create an excel spreadsheet by date to save the recorded files. Transfer those files to a memory chip to store in a secure HIPAA compliant place. Otherwise, consult with an attorney regarding the laws of your state and any further advice they may be able to offer. Further steps to protect your practice would be to install a “bank teller” like security system, and hire an expert to educate staff how to handle these situations.
Advanced prescriptions have been a courtesy in the plastic surgery industry for decades especially when meds are required prior to the surgical procedure. With the new trend of in-office procedures becoming more popular, plastic surgeons will need to develop new steps to avoid becoming victim to the drug seeker in these scenarios. Since drug seekers have no problem signing bad checks, a new financial policy requiring a cashier’s check or money order could prove beneficial. Many practices have also fallen victim to the “charge-back” scenario for cosmetic procedures. To get around this, practices have created “convenience fees” up to 4% for credit card charges of surgical services. One practice went from paying out thousands every month in merchant fees down to less than $200 a month after placing this policy without losing one single patient. If this policy is not feasible for your practice, then consider not providing prescriptions in advanced. If some prescriptions are necessary prior to surgery, requiring a non-refundable cash deposit to hold the surgery date would be advised.
As you can see, physicians need to yet again add another area of protection to their practices making the practice of medicine more challenging. These drug seekers are under pressure with state medical boards placing more accountability on the physicians. As physicians crack down on the amount of narcotics they prescribe and/or become more aware of those drug seekers in their patient files, they will also become softer targets by said drug seekers due to their credential and reputation vulnerability. Be aware of any and all situations where you could be cornered by a drug seeker. Arming yourself and staff with protecting tactics such as audio recorders could prove vital should you fall prey to the desperate drug seeker.