On April 17, 2019, the Department of Justice (DOJ) announced the indictment of 60 individuals, including 53 medical professionals, by the Appalachian Regional Prescription Opioid (ARPO) Strike Force. The ARPO Strike Force's first major criminal takedown spanned 11 federal districts and included 31 doctors, seven pharmacists, eight nurse practitioners, and seven other licensed medical professionals. The charges stem from the defendants’ alleged participation in illegally prescribing and distributing opioids and other narcotics, and for devising health care fraud schemes directed at federal health care programs, including Medicare and Medicaid. The enforcement sweep reflects the DOJ’s continued focus on medical professionals and entities within the pharmacy supply chain engaged in the unlawful distribution of prescription drugs.

The inaugural ARPO Strike Force takedown was a joint investigation by the FBI, HHS Office of the Inspector General (HHS-OIG), the U.S. Drug Enforcement Administration (DEA), the Office of Personnel Management, and the U.S. Marshals Service. In addition to its usual investigative partners, the takedown included investigative assistance from the Defense Criminal Investigative Service, the Food and Drug Administration's Office of Criminal Investigations, and several state, county, and town agencies. The breadth of the various enforcement agencies reflects the federal, state, and local commitment to combating the national opioid epidemic through enforcement.

Here are a few key takeaways from the most recent takedown:

The ARPO Strike Force Is Growing and Will Continue Aggressive Investigations and Prosecutions

The ARPO Strike Force is a joint law enforcement effort that brings together the resources and expertise of the Health Care Fraud Unit in the Criminal Division’s Fraud Section (HCF Unit), the U.S. Attorney’s Offices for 10 federal districts in six states, as well as law enforcement partners at the FBI, HHS-OIG, and the DEA.

“The mission of the ARPO Strike Force is to identify and investigate health care fraud schemes in the Appalachian region and surrounding areas, and to effectively and efficiently prosecute medical professionals and others involved in the illegal prescription and distribution of opioids,” according to the DOJ.

Formed in October 2018, the ARPO Strike Force consists of 14 prosecutors and numerous agents. The ARPO Strike Force operates out of two hubs based in the Cincinnati, Ohio/Northern Kentucky; and Nashville, Tennessee areas supporting work in the surrounding districts. While less than six months old, the enforcement initiative is already expanding. In announcing the arrests, Attorney General Barr indicated the ARPO Strike Force would expand into the Western District of Virginia, which covers Roanoke, Virginia, placing the ARPO Strike Force in 10 federal districts.

The Government Focus on Illicit Prescribing/Dispensing of Opioids Continues

The ARPO Strike Force expansion and cooperation with local investigative agencies affirm the DOJ's deep commitment to a lengthy confrontation with the opioid crisis. According to Attorney General Barr, “[t]he opioid epidemic is the deadliest drug crisis in American history, and Appalachia has suffered the consequences more than perhaps any other region, [b]ut the Department of Justice is doing its part to help end this crisis.”

HHS Secretary Alex Azar stated that, “[r]educing the illicit supply of opioids is a crucial element of President Trump’s plan to end this public health crisis,” and that the "Trump Administration’s law enforcement and public health leaders will continue to work hand in hand to end this crisis that has hit Appalachia hard and steals far too many lives across America every day.”

The DOJ will continue to direct its health care fraud units to investigate and prosecute individuals in the opioid supply chain who fraudulently prescribe and dispense prescription narcotics.

Pharmacies, Prescribers, and Non-Traditional Actors Are in the Crosshairs

The ARPO Strike Force's takedown shows that medical professionals, as well as non-traditional participants, may be charged with violations relating to opioids:

  • In the Southern District of Ohio, two doctors and three registered pharmacists were charged with several counts, including unlawful distribution of controlled substances and conspiracy to obtain controlled substances by fraud. According to the indictment, between October 2015 and October 2017 alone, one Dayton, Ohio pharmacy allegedly dispensed over 1.75 million pills.
  • In the Western District of Kentucky, a doctor was charged with controlled substance and health care fraud counts in connection with providing pre-signed, blank prescriptions to office staff who then used them to prescribe controlled substances when he was out of the office, and for directing staff at the clinic, including individuals not licensed to practice medicine, to perform medical services on patients.
  • In the Eastern District of Kentucky, a total of five people were charged, including three doctors, a dentist, and an office assistant, in connection with several health care fraud and/or controlled substance schemes. A dentist was charged for alleged conduct that included writing prescriptions for opioids that had no legitimate medical purpose and that were outside the usual course of professional practice, removing teeth unnecessarily, scheduling unnecessary follow-up appointments, and billing inappropriately for services.
  • In the Middle District of Tennessee, four doctors, four nurse practitioners, and a pharmacist were charged with various offenses for allegedly participating in illegally prescribing and dispensing opioids, other dangerous narcotics, and health care fraud schemes.
  • In the Eastern District of Tennessee, five doctors, a nurse practitioner, a physician’s assistant, and an office manager were charged in four cases. Four doctors, a nurse practitioner, and a physician’s assistant were charged with the unlawful distribution of opioids.
  • In the Western District of Tennessee, 15 individuals were charged, including eight doctors and several other medical professionals. In one case, a doctor allegedly prescribed approximately 500,000 hydrocodone pills, 300,000 oxycodone pills, 1,500 fentanyl patches, and more than 600,000 benzodiazepine pills. In another case, a nurse practitioner charged with conspiracy to unlawfully distribute controlled substances allegedly prescribed over 500,000 Hydrocodone pills, approximately 300,000 Oxycodone pills, and nearly 300,000 benzodiazepine pills (mostly Alprazolam), along with a myriad of other controlled substances.
  • In the Northern District of Alabama, multiple individuals were charged in five cases, including four doctors. In one case, the owners and operators of a medical clinic and dispensary were accused of the unlawful distribution of controlled substances and health care fraud. In that case, a doctor allegedly prescribed opioids in high dosages, dangerous combinations and, in many cases, after knowing that patients failed drug screens and were addicts, preferring cash payments and charging a “concierge fee” that ranged from approximately $50 per visit or $600 per year.
  • In the Northern District of West Virginia, an orthopedic surgeon was charged for allegedly using fraudulent prescriptions to obtain tablets of acetaminophen-codeine for his own use.
  • In the Southern District of West Virginia, a doctor was charged with allegedly distributing narcotics, including dextroamphetamine, methylphenidate, and amphetamine salt, to a patient who did not have a medical need for the drugs and whom the doctor never examined.
  • In the Eastern District of Louisiana, a neurologist at an alleged pill mill was charged with conspiracy to dispense controlled substances and conspiracy to commit health care fraud. The defendant allegedly pre-signed prescriptions for controlled substances, including oxycodone, for patients whom he did not personally examine to determine medical necessity for the prescriptions, and pre-signed prescriptions for controlled substances while he was traveling internationally.
  • In the Eastern District of Pennsylvania, a former licensed practical nurse allegedly filled fraudulent prescriptions for oxycodone in her name and the names of others at a local pharmacy to obtain the pills for herself and to distribute to others.

Looking Ahead

The DOJ's Fraud Section leads the Medicare Fraud Strike Force, which is part of a joint initiative between the DOJ and HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country. Since its inception in March 2007, the Medicare Fraud Strike Force, which maintains 14 strike forces operating in 23 districts, has charged nearly 4,000 defendants who have collectively billed the Medicare program for more than $14 billion. The Medicare Fraud Strike Force, which includes the ARPO Strike Force, has charged more than 200 individuals with opioid-related crimes.

Coordinated enforcement takedowns involving federal, state, and local agencies will continue to be part of the government’s anti-fraud enforcement arsenal and a centerpiece in the fight against opioid epidemic. The allocation of the hundreds of OIG special agents and other law enforcement personnel is a clear indication of the DOJ’s and OIG’s commitment to combating fraud in the federal health care programs.

Providers should take note:

  • Data analytics will continue to be the driver for health care fraud investigations.
  • Staying ahead of the curve and early detection by providers remain fundamental. Receipt of a government subpoena or identification of any suspicious opioid-related prescribing or dispensing activity should precipitate immediate action.
  • The government will continue to focus on doctors, pharmacists, nurse practitioners, and other licensed medical professionals that they believe are responsible for fraud.
  • Geography does not limit the scope of the DOJ's reach, as shown by the ARPO Strike Force's cases in Philadelphia and Louisiana.

Pharmacies, pharmacists, and prescribers must account for the government’s heightened scrutiny in this practice space and take proactive steps to ensure compliance with appropriate prescribing, ordering, and dispensing guidelines. While these criminal investigations are intended to identify the most egregious examples of fraud, providers must understand that any successful data analytic program requires the use of all data to identify outliers. Providers should take notice of the way the government uses billing data as an enforcement tool and take steps to avoid being a statistic in the next ARPO takedown.