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LOCK IN: Locking Out Medicaid Abuse

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Megan Thornton, a pharmacist at Walgreens, fill hundreds of prescriptions a day.  Almost all of them are for legitimate health problems – for people who legitimately need help.  But every once in a while, she comes across cases that send up a red flag.

“Unfortunately, prescription drug abuse is a problem,” says Thornton.

It’s the fastest growing form of drug abuse in the country.  And if the abuser is on Medicaid, you may be paying for their fix.

“We have seen an increase in the number of prescriptions our members are receiving,” says Kelly Williams, Clinical Operations Manger for Iowa Medicaid Enterprise.

Williams says an algorithm is used to identify clients who may be candidates for the Lock In program.

“We look at a six month review period.  If a member is utilizing three or more physicians at multiple locations, going to multiple pharmacies, three or more non-emergent E.R. visits for that time period, we consider the member for Lock In.”

A pharmacist or a physician can also make a referral.  If a medical review shows the client is in fact abusing Medicaid services, the client is forced to choose one doctor, one hospital and on pharmacist.

“If we’re processing someone who’s locked into a different store, it’ll say you can’t process this,” says Thornton.  So we just direct them that we’re unable to help them but the other store can help them.”

Nearly 2,000 people have been placed on Lock-In since it started in 2010.  That’s a five-fold increase.  And it’s saved taxpayers more than $11 million.

Medicaid clients placed on Lock-In can appeal the decision within 30 days of notification and in the event of an emergency, can still get treatment at any emergency room.

“Lock In is not meant to be detrimental and it is not meant to prevent the member from seeing the physician they need to see,” says Williams.

Instead, Williams and Thornton say the Lock In program is designed to help patients who may suffer from addiction or simply need help managing their health care.

As Thornton puts it, “We’re not here to hurt people.  We’re here to help them.”