How it works
Doctor shopping is seeing several prescribers for the same complaint without telling each about the others. The member collects overlapping prescriptions, typically for opioid painkillers, sedatives, stimulants or codeine-based medicines, and fills them at different pharmacies so that no single pharmacist sees the full picture.
Some members are dependent on the medicine. Others are part of a supply chain, recruited to collect prescriptions for resale or diversion. Organized versions use several membership numbers, dependents on the same plan or borrowed identities, and spread visits across towns or regions.
Each consultation and each script is legitimate on its own terms: a registered doctor saw the member and a registered pharmacy dispensed. The pattern is visible only across the member’s full history, where the number of prescribers, pharmacies and days of supply in a period exceeds what a single course of treatment requires.
Red flags
- Several prescribers for the same drug class within overlapping treatment periods
- Prescriptions filled at different pharmacies, often in different towns
- Early refills, or days of supply that exceed the time elapsed
- Repeated after-hours or emergency visits for pain medication with no follow-up care
- Several members of one household, or members sharing an address or phone, following the same pattern
Signals the engine evaluates
- Distinct prescribers and pharmacies per member per period for the same drug class, against the segment baseline
- Overlapping days of supply across prescriptions for the same member
- Distance between the member’s address and the prescribers and pharmacies used
- Shared addresses, phones and payer accounts linking members with the same prescribing pattern
Investigation and response
- 01Flag the member for clinical and pharmacy review before further dispensing claims are paid
- 02Alert the treating doctors and pharmacies to the overlapping prescriptions where privacy rules allow
- 03Where the member appears dependent, refer to a case manager or managed-care program rather than treating it purely as fraud
- 04Where diversion or identity misuse is indicated, refer to SIU and law enforcement and review the prescribers involved