What to do when a claimant's prescribing history shows interstate dispensing

Practical scenario: Your claimant's pharmacy records show prescriptions filled in both NSW and Victoria, but you've only been assessing NSW RTPM data. Here's your guide to complete assessment.

Published 3 April 2026

The scenario: interstate medication access

You're reviewing a CTP claim for a claimant who lives in inner-city NSW. When you request their medication review, the pharmacist notes that while most prescriptions were dispensed in NSW (captured by NSW PDDB), some prescriptions were obtained from pharmacies across the border in Victoria. You only requested NSW RTPM data, so you don't have the complete picture of what medicines your claimant obtained in Victoria. This creates a significant data gap. Now what?

Step 1: Clarify the scope of interstate dispensing

First, understand the extent of the issue. Contact your claimant or review their claim history to determine:

• Which states they accessed medicines in and when
• Whether they were residing in those states or travelling for treatment
• What reasons they had for interstate prescribing (specialist access, relocation, proximity to border, etc.)
• Whether they continue to obtain medicines in multiple states or whether it was a specific period

Step 2: Request supplementary RTPM assessment

Refer for National Database Entry (NDE) assessment and state-specific RTPM review for any states where your claimant obtained medicines. If your claimant accessed pharmacies in Victoria and NSW, you need both NSW PDDB and Victoria CPDMP data. If they accessed multiple states, you may need NDE review for controlled substance prescribing across all states.

When requesting supplementary assessment, specify:

• All states where you know or suspect medicines were obtained
• The time period covered by your claim
• Whether you need controlled substance focus (NDE) or comprehensive medication review
• Specific concerns (multiple prescribers, high-dose opioids, cross-state doctor shopping, etc.)

Step 3: Request pharmacy records from interstate location

While RTPM assessment is underway, directly request pharmacy records from interstate locations. Contact pharmacies where your claimant obtained prescriptions and request medication history records. This provides a paper trail that complements RTPM data and ensures you capture all medicines.

Information to request:

• Complete dispensing records for the claim period
• All controlled substances and other medicines
• Prescriber information and dates of dispensing
• Doses, quantities, and repeat counts

Step 4: Request medical records from interstate practitioners

If your claimant was seeing doctors in other states, request their clinical records. These records will tell you why medicines were prescribed, what treatment goals were being pursued, and whether interstate prescribing was coordinated or fragmented.

Step 5: Analyse the complete picture

Once you have NSW data, interstate RTPM data, pharmacy records, and medical records, analyse the complete medication pattern. Look for:

• Whether interstate prescribing represents legitimate access to specialist or geographically distant treatment
• Whether medicines prescribed in different states are coordinated or duplicated
• Whether doses or combinations suggest appropriate treatment or potential misuse
• Whether interstate prescribers were aware of each other's involvement
• Whether the total medication burden makes sense given the injury or claim history

Step 6: Address gaps in treatment coordination

If interstate dispensing reveals coordination gaps (prescribers in different states who don't know about each other's involvement), refer for medication coordination. This involves identifying a primary prescriber in one state who will coordinate all medication management, regardless of which state medicines are dispensed in. All other prescribers should be copied on correspondence and coordinated through the primary prescriber.

When interstate dispensing indicates concern

If interstate dispensing reveals problematic patterns (doctor shopping across borders, uncoordinated high-dose prescribing, duplicated medicines, or evidence of medicine diversion), consider escalation:

• Refer to your claims manager or medical advisor
• Consider impact on claim liability and medication funding
• If fraud is suspected, refer to appropriate authorities
• Consult legal advice about claim management implications

Step 7: Establish monitoring for ongoing interstate access

If your claimant continues to access medicines across state borders, establish a monitoring protocol. This might include:

• Quarterly RTPM review across all relevant states
• Requirement that all interstate prescriptions be approved by a primary prescriber
• Communication to treating teams in all states about coordination requirements

The bottom line for interstate dispensing scenarios

Interstate dispensing is a data gap that must be closed before you can properly assess medication risk. Don't assume state-based RTPM data alone is sufficient. Close the gaps through NDE assessment, interstate pharmacy records, and medical record review. This gives you the complete picture you need to make informed decisions about medication safety, treatment appropriateness, and claim management in a complex multi-state situation.