I'm working with a guy right now who has a blood clotting disease and his meds alone are $800k yr before all the inpatient stays and procedures.
Generally once the patient starts spending and hits certain level of cost they get assigned a case manager through their insurance to 1. see if they're getting proper treatment 2. try to streamline them to the correct care first (rule out needless and repeat visits) 3. make sure all procedures and drugs are medically necessary. The people that go beyond these case managers sometimes go to a different organization for medical management.
Some states are getting even more strict, in Alaska right now if you have Medicaid and go to the doctor too much for what they view as needless visits you actually get cut off from ALL providers and then can only see certain approved providers for certain approved types of visits, can only get prescribed specific drugs and you have to "graduate" from that program after a year in order to get out of it by keeping ER visits to less than 1 every 6 months. I'll try and find you a link with more info about that program but they're trying to keep it on the dl because obviously all the patients who get put on that program are pretty outraged & they don't want the bad press about it, the perception of denying care etc.
Also everyone in the AK medicaid who is on opiates has to abide by a "pain contract" including random drug testing and med count checks and if they screw up too many times they will get banned from certain doctors/facilities, put on a stricter program (like the above) and can get kicked off Medicaid. Unfortunately this just leads to more homeless heroin addicts, so I can't really say that program has been a success.
Edit: link http://www.adn.com/article/20140703/state-aims-curb-overuse-...