Opioid Overutilization

Because of the risks involved with opioid and acetaminophen use, both Blue Cross and Blue Shield of Nebraska (BCBSNE) and CMS urge physicians to prescribe opioids with caution and carefully monitor patients using these medications. CMS requires BCBSNE to actively monitor claims data for potential opioid and/or acetaminophen overuse. If our analysis suggests potential overuse, we send a letter to the prescriber detailing our concerns and ask them to complete and return a questionnaire about the patient’s condition and treatments. If the physician verifies that the current opioid therapy is medically necessary, safe and appropriate for their patient, we’ll follow up with a letter of confirmation and report our findings to CMS.  

If the physician fails to respond to our request for information or agrees that the current opioid therapy is not appropriate, BCBSNE may stop or limit coverage for the patient’s opioid medication and notify the member, prescribers and report our findings to CMS.  

Our analysis looks at:  

• Safety risks, such as instances when a patient receives a daily dosage of opioids — either from a single prescription, or multiple prescriptions – that’s higher than established safety levels.  
• High utilization patterns, where a patient may have opioid prescriptions from multiple physicians within the same time period.  
• Potential fraud, waste or abuse, when a patient visits multiple physicians to expand their access to these painkillers, a practice known as “doctor shopping.”