Testimony Before the United States House of Representatives 
Committee on Ways and Means 
Subcommittee on Oversight 
 
 
 
 
The Opioid Crisis: The Current Landscape and 
CMS Actions to Prevent Opioid Misuse 
 
Testimony of: 
 
Gary Cantrell 
Deputy Inspector General for Investigations  
Office of Investigations 
  Office of Inspector General    
Department of Health and Human Services 
 
 
 
 
 
January 17, 2018 
10:00 a.m. 
Location: Longworth House Office Building, Room 1100 
 
    Testimony of: Gary Cantrell 
Deputy Inspector General for Investigations 
   Office of Inspector General, U.S. Department of Health and Human Services 
 
Good morning, Chairman Jenkins, Ranking Member Lewis, and distinguished members of the 
Subcommittee.  I am Gary Cantrell, Deputy Inspector General for Investigations with the U.S. 
Department of Health and Human Services (HHS), Office of Inspector General (OIG).  
I appreciate the opportunity to appear before you to discuss how OIG is combatting the opioid 
crisis in Federal health care programs.   
 
OIGs mission is to protect the integrity of HHS programs and the health and welfare of the 
people they serve through prevention, detection, and enforcement.  To accomplish our mission, 
OIG uses data analytics and real-time field intelligence to detect and investigate program fraud 
and to focus our resources for maximum impact.  We are a multidisciplinary organization 
comprised of investigators, auditors, evaluators, analysts, clinicians, and attorneys. In addition, 
we depend on strong public and private partnerships to ensure coordinated enforcement success.  
OIG has identified curbing the opioid epidemic as one of the Departments Top Management and 
Performance Challenges in 2017.  Key components of that challenge include addressing 
inappropriate prescribing of opioids, inadequate access to treatment, and misuse of grant funds as 
well as combatting fraud by treatment providers of opioid use disorders and diversion of 
prescription opioids and potentiator drugs.1  
 
OIG has a longstanding and extensive history of enforcement and oversight work focused on 
prescription drug fraud, drug diversion, pill mills, medical identity theft, and other schemes that 
put people at risk of harm.  Several years ago, OIG detectedand began taking action to 
addressa rise in fraud schemes involving opioids, as well as associated potentiator drugs.  In 
addition to increasing our investigative efforts to combat prescription drug abuse, we have 
responded to the growing severity of the opioid epidemic by focusing on work that identifies 
opportunities to strengthen program integrity and protect at-risk beneficiaries.  OIG uses 
advanced data analytics tools to put timely, actionable data about prescribing, billing, and 
utilization trends and patterns in the hands of investigators, auditors, evaluators, and government 
partners.  Our goal is to identify opportunities to improve HHS prescription drug programs to 
reduce opioid addiction, share data and educate the public, and identify and hold accountable 
perpetrators of opioid-related fraud. 
 
In my testimony today, I will highlight law enforcement activities led by my Office of 
Investigations and discuss OIGs current efforts to combat opioid-related fraud, waste, and 
abuse.  I also will highlight key OIG recommendations that would, if implemented, have a 
positive impact on the opioid problem.   
 
OIGS OFFICE OF INVESTIGATIONS TARGETS FRAUD, WASTE, AND ABUSE 
 
OIGs Office of Investigations has investigators covering every State, the District of Columbia, 
Puerto Rico, and other U.S. territories.  We collaborate with other Federal, State, and local law 
enforcement authorities to maximize our impact.  Special Agents in our Office of Investigations 
                                                           
1 Drugs that enhance the high or euphoria when combined with controlled substances. 
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House Committee on Ways and Means, Subcommittee on Oversight 
January 17, 2018  have full law enforcement authority and use a broad range of investigative actions, including the 
execution of search and arrest warrants, to accomplish their mission.  OIG and its law 
enforcement partners combine resources to detect and prevent health care fraud, waste, and 
abuse.  During the last 3 fiscal years (FYs 2015 to 2017), OIG investigations have resulted in 
more than $10.8 billion in investigative receivables (dollars ordered or agreed to be paid to 
Government programs as a result of criminal, civil, or administrative judgments or settlements); 
2,650 criminal actions; 2,211 civil actions; and 10,991 program exclusions.2 
  
Much of this work involves the Medicare and Medicaid programs and is funded by the Health 
Care Fraud and Abuse Control Program (HCFAC).  The HCFAC provides funding resources to 
the Department of Justice (DOJ), HHS, and OIG, which are often used collaboratively to fight 
health care fraud, waste, and abuse.  Since its inception in 1997, the HCFAC has returned more 
than $31 billion to the Medicare trust fund.  OIG is a lead participant in the Medicare Fraud 
Strike Force, which combines the resources of Federal, State, and local law enforcement entities 
to fight health care fraud across the country.  Finally, OIG collaborates with State Medicaid 
Fraud Control Units (MFCUs) to detect and investigate fraud, waste, and abuse in State 
Medicaid programs. 
   
THE OPIOID CRISIS 
 
Opioid use is a rapidly growing national health care problem, and our Nation is in the midst of an 
unprecedented opioid epidemic.3  More than 50,000 Americans died from drug overdoses in 
2015, of which 63 percent reportedly involved opioids.4  Deaths from prescription pain 
medication remain far too high, and in 2014, the most recent year on record, there was a sharp 
increase in heroin-involved deaths and an increase in deaths involving synthetic opioids such as 
fentanyl.5  According to the Centers for Disease Control and Prevention (CDC), approximately 
three out of four new heroin users report having abused prescription opioids prior to using 
heroin.  Prescription drug diversionthe redirection of prescription drugs for an illegal 
purposeis a serious component of this epidemic. 
   
OIGS OPIOID FRAUD ENFORCEMENT EFFORTS 
 
Opioid fraud encompasses a broad range of criminal activity from prescription drug diversion to 
addiction treatment schemes.  Many of these schemes can be complex, involving complicit 
patients or beneficiaries who are not ill, kickbacks, medical identity theft, money laundering, and 
criminal enterprises.  The schemes also involve multiple co-conspirators and health care 
professionals such as physicians, nonphysician providers, and pharmacists.  These investigations 
                                                           
2 OIG has the authority to exclude individuals and entities from federally funded health care programs.  The effect of 
an exclusion is that no payment will be made by any Federal health care program for any items or services 
furnished, ordered, or prescribed by an excluded individual or entity.  No program payment will be made for 
anything that an excluded person furnishes, orders, or prescribes. 
3  Centers for Disease Control and Prevention, Prescription Painkiller Overdoses at Epidemic Levels [press release], 
Nov. 1, 2011. 
4 Executive Office of the President, The Council of Economic Advisors:  The Underestimated Cost of the Opioid 
Crisis  
5Health and Human Services, The Opioid Epidemic: By the Numbers [Fact Sheet], June 2016. 
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House Committee on Ways and Means, Subcommittee on Oversight 
January 17, 2018  can be complex and often involve the use of informants, undercover operations, and surveillance. 
 
2017 National Health Care Fraud Takedown 
 
OIG and our Medicare Strike Force partners led the 2017 National Health Care Fraud Takedown.  
The Takedown was the largest ever health care fraud enforcement action, resulting in 412 
charged defendants across 41 Federal districts, including 115 doctors, nurses, and other licensed 
medical professionals, for their alleged participation in health care fraud schemes involving 
approximately $1.3 billion in false billings.  Over 120 defendants, including doctors, were 
charged for their roles in prescribing and distributing opioids and other dangerous narcotics.6 
OIG also announced 295 opioid-related exclusions.  The enforcement operation brought together 
more than 1,000 Federal and State law enforcement personnel, including 350 OIG Special 
Agents and 30 MFCUs. 
 
Case Examples 
 
The following are cases our agents have investigated.  These case examples highlight opioid 
fraud schemes related to prescriber fraud, pharmacy fraud, and treatment/drug-testing fraud: 
  
Prescriber Fraud 
 
  Dr. Jaime Guerrero, an anesthesiologist in Kentucky, pled guilty to knowingly and 
intentionally distributing and dispensing Schedule II and III controlled substances to 
patients without a legitimate medical purpose.  In one instance, Guerreros distribution 
and dispensing of hydrocodone caused the death of one of his patients.  Guerrero also 
pled guilty to three counts of health care fraud for fraudulently billing various health care 
benefit programs and for submitting fraudulent claims for patient health care counseling.  
Guerrero was sentenced to more than 8 years of imprisonment, agreed to pay $827,000 in 
restitution to nine health care benefit programs, and forfeited his medical license and real 
property. 
 
  In Pennsylvania, Dr. William J. OBrien III worked with Pagans Motorcycle Club, an 
outlaw gang known for violence and drug dealing, to operate a pill mill out of his 
medical offices.  OBrien wrote fraudulent prescriptions for oxycodone and other drugs, 
while the Pagans recruited pseudo-patients to buy the fraudulent prescriptions.  After 
filling the prescriptions, the Pagans resold the pills on the street.  OBrien distributed 
more than 700,000 pills containing oxycodone and other Schedule II controlled 
substances in furtherance of the conspiracy.  OBrien was sentenced to 30 years of 
imprisonment and ordered to pay $5.3 million in restitution. 
 
Pharmacy Fraud 
 
  Babubhai Patel was a licensed pharmacist who either owned or controlled 26 pharmacies 
in Michigan.  Patel concealed his ownership and control over many of his pharmacies 
                                                           
6 Department of Justice, National Health Care Fraud Takedown Results in Charges Against Over 412 Individuals 
Responsible for $1.3 Billion in Fraud Losses, July 2017. 
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House Committee on Ways and Means, Subcommittee on Oversight 
January 17, 2018  through the use of straw owners.  Patel offered and paid kickbacks, bribes, and other 
inducements to prescribers in exchange for their writing fraudulent opioid prescriptions 
for patients with Medicare, Medicaid, and private insurance and directing the patients to 
fill their prescriptions at one of Patels pharmacies.  Patel and his pharmacists billed 
Medicare and other insurers for dispensing the medications despite the fact that the 
medications were medically unnecessary and/or were never provided.  Patels pharmacies 
dispensed approximately 250,000 doses of OxyContin, 4.6 million doses of Vicodin, 1.5 
million doses of Xanax, a potentiator drug, and 6,100 pint bottles of codeine cough syrup.  
Patels pharmacies falsely billed Medicare and Medicaid approximately $57.8 million for 
medications purportedly provided to beneficiaries over the course of the scheme.  Patel 
was sentenced to 17 years of imprisonment and ordered to pay $18.9 million in joint and 
several restitution.     
 
  Michigan pharmacist Nadeem Iqbal owned and operated two pharmacies that he used to 
illegally distribute more than 200,000 doses of opioid medications such as OxyContin, 
oxycodone, and hydrocodone as part of a diversion scheme that billed the Medicare and 
Medicaid programs.  Iqbal filled prescriptions for runners who presented as many as 25 
prescriptions at a time for patients.  The diverted opioids were later sold on the street for 
profit.  Iqbal also tried to maintain a ratio of 70 percent noncontrolled prescriptions to 30 
percent controlled prescriptions to avoid detection.  Iqbal was sentenced to more than 4 
years of imprisonment and ordered to pay over $1.6 million in restitution.   
 
Treatment/Drug Testing Fraud 
 
  In a Massachusetts case worked with our MFCU partners, Dr. Punyamurtula Kishore and 
his company, Preventive Medicine Associates, Inc., pled guilty to charges of Medicaid 
kickbacks, Medicaid false claims, and larceny.  Dr. Kishore owned and managed a 
network of 29 medical branches throughout Massachusetts under Preventive Medicine 
Associates and engaged in a complex scheme to pay bribes and kickbacks to induce sober 
homeowners to have their residents use his labs for drug screening of their urine samples.  
Drug screens are generally billed to the Massachusetts Medicaid program, MassHealth, 
for approximately $100 to $200.  Dr. Kishore manipulated his business relationships with 
owners of sober homes to illegally obtain tens of thousands of drug screens paid for by 
MassHealth for sober house residents who were never treated by Preventive Medicine 
Associates providers.  Kishore was sentenced to serve 11 months of imprisonment 
followed by 10 years of probation and ordered to pay $9.3 million in restitution. 
 
  In Virginia, OIG worked with our MFCU partners on a case involving the owners of a 
drug-screening lab for testing urine samples and an addiction practice who were engaged 
in a scheme to bill for unnecessary drug-screening tests of urine samples.  Beth Palin and 
Joseph Webb owned Bristol Labs and Mtn. Empire Medical Care and used the businesses 
to bill expensive, medically unnecessary tests to insurance companies.  At the facilities, 
uninsured or self-pay patients received a $25 dip-stick or quick cup drug screen of a 
urine sample from Bristol Labs.  However, if a patient was paying through insurance, 
Medicaid, or Medicare, Bristol Labs performed two separate, automated screens.  These 
patients paid nothing out of pocket; however, Medicare, Medicaid, or their insurance 
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House Committee on Ways and Means, Subcommittee on Oversight 
January 17, 2018  company would be billed between $120 and $1,800 for the tests each week.  The tests 
were medically unnecessary, and the results of the tests were not used to direct patient 
care.  The conspiracy fraudulently billed the Virginia Medicaid program, the Tennessee 
Medicaid program (TennCare), Medicare, and other insurers for medically unnecessary 
urine screens.  Palin and Webb were both sentenced to 3 years of imprisonment and 
ordered to pay more than $1.4 million in restitution.   
 
OIGS EFFORTS TO COMBAT THE OPIOID EPIDEMIC GO BEYOND 
ENFORCEMENT 
 
Data Analytics  
 
The OIG, including the Office of Investigations and OIGs Chief Data Office, use data analytics 
to detect and investigate health care fraud, waste, and abuse.  Our Chief Data Office analyzes 
billions of data points and claims information to identify trends that may indicate fraud, 
geographical hot spots, emerging schemes, and individual providers of concern.  At the macro 
level, OIG analyzes data patterns to assess fraud risks across Medicare services, provider types, 
and geographic locations to prioritize and deploy our resources.  At the micro level, OIG uses 
data analytics, including near-real-time data, to identify potential fraud suspects for a more in-
depth analysis and efficiently target investigations. 
 
OIG Data Brief 
 
In July 2017, OIG released a data brief entitled Opioids in Medicare Part D: Concerns about 
Extreme Use and Questionable Prescribing7 in conjunction with the 2017 National Health Care 
Fraud Takedown.  We found the following:  
 
One in three Medicare Part D beneficiaries received opioids in 2016.  In total, 14.4 million 
beneficiaries received an opioid prescription that year. 
 
Approximately 500,000 beneficiaries received high amounts of opioids.  To identify these 
beneficiaries, OIG looked at the morphine equivalent dose (MED) received by each beneficiary, 
which equates all of the various opioids and strengths into one standard value.  Beneficiaries who 
received high amounts of opioids had an average daily MED greater than 120 mg for at least 3 
months in 2016.  A daily MED of 120 mg is equivalent to taking 12 tablets a day of Vicodin 
10 mg or 16 tablets a day of Percocet 5 mg.  These dosages far exceed the amounts that the 
manufacturers recommend.  Beneficiaries with a cancer diagnosis and those enrolled in hospice 
were excluded from the analysis.  Although beneficiaries may receive opioids for legitimate 
purposes, these high amounts raise concern due to the health risks associated with opioids.  
 
OIG identified nearly 90,000 beneficiaries at serious risk of opioid misuse or overdose.  OIG 
identified two groups of beneficiaries at serious risk of opioid misuse or overdose: (1) 
beneficiaries who received extreme amounts of opioids and (2) beneficiaries who appeared to be 
                                                           
7 OIG, Opioids in Medicare Part D: Concerns about Extreme Use and Questionable Prescribing, OEI-02-17-00250, 
July 2017. 
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House Committee on Ways and Means, Subcommittee on Oversight 
January 17, 2018  doctor shopping.8  OIG identified 69,563 beneficiaries who received extreme amounts of 
opioids.  They each had an average daily MED of more than 240 mg for the entire year. 
 
OIG also identified 22,308 beneficiaries who appeared to be doctor shopping.  They each 
received high amounts of opioids and had four or more prescribers and four or more pharmacies 
for opioids.  While some of these beneficiaries may not have been doctor shopping, receiving 
opioids from multiple prescribers and multiple pharmacies may still pose dangers from lack of 
coordinated care.  Typically, beneficiaries who receive opioids have just one prescriber and one 
pharmacy. 
 
OIG identified about 400 prescribers with questionable opioid prescribing patterns for 
beneficiaries at serious risk.  In the data brief, a total of 401 prescribers stood out as having 
questionable prescribing patterns; they ordered opioids for the highest numbers of beneficiaries 
at serious risk (i.e., those who received extreme amounts of opioids or appeared to be doctor 
shopping).  In total, prescribers with questionable billing patterns wrote 265,260 opioid 
prescriptions for beneficiaries at serious risk, costing Part D a total of $66.5 million.   
 
Although some patients may legitimately need high amounts of opioids, questionable prescribing 
patterns can indicate that prescribers are not checking State databases that monitor prescription 
drugs, or that they are ordering medically unnecessary drugs that may be diverted for resale or 
recreational use.  Another possibility is that the prescribers identification was sold or stolen and 
is being used for illegal purposes.  Questionable patterns also raise significant concern that 
prescribers may be operating pill mills.  A pill mill is a doctors office, clinic, or health care 
facility that routinely prescribes controlled substancessuch as oxycodoneoutside the scope 
of professional practice and without a legitimate medical purpose. 
 
Ensuring the appropriate use and prescribing of opioids is essential to protecting the health and 
safety of beneficiaries and the integrity of Part D.  Prescribers play a key role in combatting 
opioid misuse.  They must be given the information and tools needed to appropriately prescribe 
opioids when medically necessary.  States prescription-drug-monitoring programs can provide 
invaluable information to prescribers about a patients opioid prescription history.  Prescribers 
must be vigilant about checking the State monitoring databases to ensure that their patients are 
receiving appropriate doses of opioids and to better coordinate patient care.  At the same time, 
the Department must address prescribers with questionable prescribing patterns for opioids to 
ensure that Medicare Part D is not paying for unnecessary drugs that are being diverted for resale 
or recreational use. 
 
Additional OIG Efforts Currently Underway 
 
OIG is expanding our portfolio of audits and evaluations addressing opioid issues by focusing on 
work that identifies opportunities to strengthen program integrity and protect at-risk beneficiaries 
across multiple departmental programs.  OIG currently has seven opioid-related audits or 
evaluations underway.  They address the following issues:  
 
                                                           
8 Other beneficiaries may also be at serious risk of opioid misuse or overdose, but they were not the focus of this 
data brief. 
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House Committee on Ways and Means, Subcommittee on Oversight 
January 17, 2018    questionable prescribing patterns in Medicaid;  
  Medicaid program integrity controls;  
  CDCs oversight of grants to support programs to monitor prescription drugs; 
  the Food and Drug Administrations oversight of opioid prescribing through its risk 
management programs; 
  the Substance Abuse and Mental Health Services Administrations oversight of 
opioid treatment program grants; 
  beneficiary access to buprenorphine medication-assisted treatment; and 
  opioid prescribing practices in the Indian Health Service.   
 
Additionally, OIG is developing a toolkit that a variety of health care entities, such as insurers 
and enforcement organizations, can use to analyze opioid claims data to identify patients at risk 
of opioid misuse.  We will also continue our efforts to educate communities, providers, patients, 
private plans, and others on how to detect fraud and abuse related to the opioid crisis. 
 
OIG MAXIMIZES IMPACT THROUGH STRONG COLLABORATION WITH PUBLIC 
AND PRIVATE PARTNERS 
 
In addition to Strike Force operations and other government collaborations, OIG engages with 
private sector stakeholders to enhance the relevance and impact of our work to combat health 
care fraud, as demonstrated by our leadership in the Healthcare Fraud Prevention Partnership 
(HFPP) and collaboration with the National Health Care Anti-Fraud Association (NHCAA).  
OIG strives to cultivate a culture of compliance in the health care industry through various 
educational efforts, such as Pharmacy Diversion Awareness Conferences, public outreach, and 
consumer education.   
 
Medicare Fraud Strike Force  
 
The Strike Force effort began in Miami in March 2007 and has expanded operations to eight 
additional cities.  Strike Force teams effectively harness the efforts of OIG and DOJ, including 
Main Justice, U.S. Attorneys Offices, and the Federal Bureau of Investigation (FBI), as well as 
State and local law enforcement, to fight health care fraud in geographic hot spots. 
 
The Strike Force teams use near-real-time data to pinpoint potential fraud hot spots and identify 
aberrant billing.  This coordinated and data-driven approach to identify, investigate, and 
prosecute fraud has produced significant results, highlighted by the July 2017 National Health 
Care Fraud Takedown.  Since its inception in March 2007, the Strike Force has charged more 
than 3,000 defendants who collectively billed the Medicare program more than $10.8 billion. 
 
Collaboration with the Department 
OIG collaborates with a number of HHS agencies, including the Centers for Medicare & 
Medicaid Services (CMS) and the Agency for Community Living (ACL), on fraud and opioid-
related initiatives.  OIG collaborates with CMS and ACL to educate providers, the industry, and 
beneficiaries on the role each one plays in the prevention of prescription drug and opioid-related 
fraud and abuse.  We share our analytic methods and data analysis with CMS and work together 
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House Committee on Ways and Means, Subcommittee on Oversight 
January 17, 2018  to identify mitigation strategies and develop follow-up approaches to deal with the prescribers 
and at-risk beneficiaries identified.  OIG engages ACLs Senior Medicare Patrol and State 
Health Insurance Assistance Program through presentations on the prevention of fraud, waste, 
and abuse. 
Opioid Fraud and Abuse Detection Unit 
 
OIG provided critical support in the establishment of the new Opioid Fraud and Abuse Detection 
Unit established by the Attorney General in collaboration with OIG, FBI, and Drug Enforcement 
Administration (DEA).  The unit focuses specifically on opioid-related health care fraud using 
data to identify and prosecute individuals who are contributing to the opioid epidemic.  This 
collaboration led to the selection of 12 judicial districts around the country where OIG has 
assigned Special Agents to support 12 prosecutors identified by DOJ to focus solely on 
investigating and prosecuting opioid-related health care fraud cases.  Each of the 12 districts is 
supported by OIG, FBI, and DEA.   
The Healthcare Fraud Prevention Partnership and the National Healthcare Anti-Fraud 
Association 
 
The HFPP and NHCAA are publicprivate partnerships that address health care fraud by sharing 
data and information for the purposes of detecting and combatting fraud and abuse in health care 
programs.  OIG is an active partner in these organizations and frequently shares information 
about prescription-drug fraud schemes, trends, and other matters related to health care fraud.   
Pharmacy Diversion Awareness Conferences 
 
OIG has collaborated with the Drug Enforcement Administration to provide anti-fraud education 
at numerous Pharmacy Diversion Awareness Conferences held across the United States.  The 
conferences were designed to assist pharmacy personnel with identifying and preventing 
diversion activity.  Since 2013, OIG has presented at conferences in 50 States and Puerto Rico. 
 
TOP OIG RECOMMENDATIONS FOR CMS RELATED TO THE OPIOID CRISIS 
 
Ensuring the appropriate use and prescribing of opioids is essential to protecting the health and 
safety of beneficiaries and the integrity of Part D.  It is necessary to address prescribers with 
questionable prescribing patterns for opioids to ensure that Medicare and Medicaid do not pay 
for unnecessary drugs that are harming beneficiaries or being diverted for resale or recreational 
use. 
 
1) Restrict certain beneficiaries to a limited number of pharmacies or prescribers.  
 
OIG recommends that CMS encourage implementation of the new Medicare Part D beneficiary 
lock-in authority under the Comprehensive Addiction and Recovery Act of 2016 
(CARA).  Lock-in would restrict certain beneficiaries to a limited number of pharmacies or 
prescribers when warranted and reduce inappropriate use of opioids among Medicare 
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House Committee on Ways and Means, Subcommittee on Oversight 
January 17, 2018  beneficiaries and Part D fraud.  This policy would provide coordination of care for beneficiaries 
being harmed by overprescribing and address beneficiaries who are doctor shopping or 
intentionally seeking unnecessary prescriptions. 
 
2) Expand drug utilization review programs to include additional drugs susceptible to fraud, 
waste, and abuse.  
 
Drug utilization reviews are intended to protect beneficiaries and reduce fraud, waste, and 
abuse.  However, CMSs requirements for these reviews apply only to certain types of 
drugs.  We recommend that CMS and plan sponsors monitor beneficiary utilization for a wider 
range of drugs susceptible to abuse than they currently do.  In particular, we recommend 
expanding sponsors and CMSs drug utilization reviews to cover certain noncontrolled 
substances such as HIV and antipsychotic medications that are used in combination with opioids 
as potentiators.   
 
3) Require plan sponsors to report to CMS all potential fraud and abuse and any corrective 
actions they take in response.  
 
CMS should collect comprehensive data from Part D plan sponsors to improve its oversight of 
their program integrity efforts, including the diversion of opioids for illegitimate use.  Sponsors 
serve as the first line of defense against opioid fraud, waste, and abuse in Part D as they are 
responsible for paying claims and monitoring billing patterns.  However, there is currently a lack 
of transparency on how Part D sponsors identify and investigate these matters.  
 
4) Improve Medicaid data.  
 
CMS does not have complete and accurate data needed to effectively oversee the Medicaid 
program, including opioids.  Without accurate claims data, adequate oversight of the Medicaid 
program is compromised.  OIG has a history of work that points to the incompleteness and 
inaccuracy of CMSs national Medicaid database, the Transformed Medicaid Statistical 
Information System (T-MSIS).  Without a national dataset, CMS, States, and OIG are unable to 
identify nation-wide trends and vulnerabilities.  This hampers program integrity efforts because 
fraud does not respect State boundaries.  OIG recommends that CMS establish a deadline for 
when national T-MSIS data will be available for multistate program integrity efforts. 
 
CONCLUSION 
 
OIG has made combatting the opioid crisis a top enforcement and oversight priority.  We will 
continue to leverage our analytic, investigative, and oversight tools, as well as our partnerships in 
the law enforcement and program integrity communities and with the Department to maximize 
our efforts.  OIG will remain vigilant in following and investigating emerging opioid fraud 
trends, especially schemes involving patient harm and abuse. 
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House Committee on Ways and Means, Subcommittee on Oversight 
January 17, 2018