Eligibility screening is performed by a system separate from but often utilized with PRODUR systems. These systems reported screening over 31.7 million prescription drug claims during 12-month periods between January 1994 and June 1995, and sent pharmacists alerts of potentially inappropriate drug therapy for about 6.3 million (20 percent) of these claims. Program Costs Can Be Significantly Reduced

Along with increasing patient safety, the PRODUR systems in the states we reviewed reduced Medicaid program costs by millions of dollars annually through the cancellation of potentially wasteful prescriptions and the denial of prescriptions to ineligible recipients. States Implement Systems Differently, Often Not Sharing Experiences

The states in our review have all implemented their automated PRODUR systems differently, in large part because no overall source of information or guidance for implementing PRODUR systems exists. Each state has its own DUR board, which independently sets screening criteria and policies. In August 1994 HCFA issued guidelines to assist the states in estimating and reporting the costs and benefits of both retrospective and prospective drug utilization review. It stated that PRODUR systems are not specifically designed to detect Medicaid fraud and abuse and that retrospective DUR systems may be more capable of detecting potentially fraudulent activity and referring this activity to states’ Medicaid Surveillance Utilization Review units for follow-up.
Why GAO Did This Study

Pursuant to a congressional request, GAO reviewed states' experiences with automated prospective drug utilization review (PRODUR) systems in their Medicaid programs, focusing on: (1) how these systems can improve patient safety, control program costs, and reduce fraud, waste, and abuse; and (2) impediments to effective implementation of PRODUR systems.

What GAO Found

GAO found that: (1) between January 1994 and June 1995, PRODUR systems reviewed screened over 31.7 million prescription drug claims, and alerted pharmacists to potentially inappropriate drug treatments; (2) over 650,000 prescriptions were cancelled because of potential risks to patients; (3) PRODUR systems have reduced Medicaid costs by denying prescriptions to ineligible recipients, preventing hospitalizations due to illnesses caused by inappropriately prescribed drugs, and detecting and eliminating fraud and abuse; (4) PRODUR systems are more cost-effective than traditional review systems; (5) states implement their PRODUR systems differently because there is no guidance on PRODUR system implementation; and (6) each state has its own drug utilization review board which independently sets screening criteria and policies, but states have no systematic way to share experiences and best practices.