Medicare Part D Opioid Prescribing Integrity Analytics

Data-driven framework identifying high-risk prescribing patterns to enhance patient safety and fiscal integrity

Medicare Part D Payments
$128.2B
Annual payments to plans (2023)
Annual Excess Costs
$1.22B
Identified through analysis
High-Risk Prescribers
51,660
5.0% of total (1.03M analyzed)
Projected Recovery
$122-244M
Based on 10-20% historical rate
Model Concordance
61.6%
ML vs Statistical methods
Maximum ROI
45:1
Comprehensive implementation

Top States by Excess Medicare Costs

Implementation ROI by Scenario

Regional Anomaly Rates

Phased Recovery Projections

Implementation Roadmap

Phase Timeline Scope Investment Projected Recovery ROI
Phase I Years 1-2 Top 100-500 prescribers pilot $3-5M annually $5-10M (Y1), $25-50M (Y2) 3-5:1
Phase II Years 3-4 All 51,660 high-risk prescribers $10-15M annually $60-120M (Y3), $122-244M (Y4) 8-16:1
Phase III Years 5+ Multi-payer exploration $20-30M $300-500M across all programs 15-25:1

System Performance Metrics

Metric Value Significance
Total Prescribers Analyzed 1.38 million Complete Medicare Part D coverage
Processing Time 47.3 seconds Comprehensive real-time analysis
Peer Groups Established 2,020 Specialty-geographic combinations
Clinical Exclusions 7,701 Oncology/hospice appropriately excluded
2-Year Persistence 63% Projected pattern stability
Bootstrap Stability 2.3% error High statistical confidence

Analysis based on CMS Medicare Part D Prescriber Public Use File, OIG exclusion database, and federal enforcement data

Recovery projections based on historical 10-20% recovery rates from Department of Justice healthcare fraud enforcement