Ways to Ensure Prescription Medication is Appropriate

The challenge:   A grey zone medication is any type of drug for which special attention is required to determine if it is appropriate for the injured worker based on compensability, relation to injury and medical history. Ensuring medications are appropriate has become increasingly complex due to an aging and unhealthy workforce. Workers who have more simultaneous ailments are leading to the use of medications that are unrelated to the actual injury.
The most common grey zone medication categories mirror the prescription trends within workers compensation as a whole; antibiotics, pain medications, hypnotics, anticonvulsants, antidepressants, ulcer medications, cardiovascular medications.
The solution: Implementing effective strategies to monitor grey zone medications helps ensure injured worker safety and reduces opportunities for instances of fraud, misuse and abuse.
  1. Develop customized medication plans
By working with a pharmacy benefit manager (PBM), payors can create medication plans that are based on specific criteria to ensure that medications are appropriate for the injured worker. Medication plans should be specific to body part and nature of injury, as well as the acute or chronic nature of the injury. PBMs should also offer electronic notification of approved and misaligned medications. This will reduce administrative burdens on claims professionals, allowing them to focus on jurisdictional issues related to the claim while the PBM can focus on medication concerns.
  1. Establish comprehensive utilization management programs
Utilization management programs are essential to limit cases of fraud, misuse and abuse and ultimately ensure injured worker safety. A quality program should include working with a clinical staff capable of performing in-depth, injured worker-specific drug utilization reviews. While PBMs offer utilization review programs, payors should also ensure their partner has a process in place that is managed by clinical pharmacists. The clinical utilization review program should use a combination of evidence-based medical guidelines, peer review journals and recommendations provided by government organizations.
·    Prospective utilization reviews– A prospective program allows all involved parties to plan for future outcomes with up-front information. Guiding future decisions through historical data and practices allows for the achievement of cost control and utilization control.


·   Concurrent utilization reviews– A concurrent program can prevent abuse involving the use of multiple pharmacies and physicians for different medications, or excessive early refill attempts. The PBM can trigger concurrent alerts to inform the dispensing pharmacist about possible reasons a medication should be questioned before filling. This process can ensure that prescriptions are not filled at the point-of-sale unless the medication is allowed or the PBM receives authorization from the payor.
Retrospective drug utilization reviews and clinical intervention programs– Conducting retrospective drug utilization reviews, physician monitoring and clinical intervention programs should be used to continually evaluate claims for grey zone medications and monitor inappropriate and/or excessive use. Staying on top of potential patterns can cut back on unnecessary spending and ensure injured worker safety.


·     Retrospective reviews– After a prescription is filled, the PBM’s clinical pharmacist team should audit the claim for indicators of misuse; multiple physicians, duplication of therapy, excessive duration and use.
 .  Clinical intervention programs– Seek a PBM that offers a wide range of clinical intervention programs to assist with evaluation needs. The range of programs should consist of registered pharmacists, nurses and other health professionals available for consultation on medication questions and peer reviews. The PBM’s clinical intervention team should provide recommendations for specific claims that require further evaluation.
  1. Physician monitoring
It is essential to have a process that monitors an injured worker with multiple physicians. A successful program should be based on established best practices and contain multiple components including:
    • Monitoring for appropriate medication utilization using evidence-based published therapeutic guidelines
    • Overseeing prescribing patterns at the physician level to establish appropriate/inappropriate use of brand name medications when an FDA approved generic equivalent exists
    • Participating in mandatory and voluntary state reporting programs that monitor for excessive prescribing patterns
    1. Pharmacist support
    The PBM must have a staff of clinical pharmacists available to provide customized support for medication-related decisions. The exchange of medication education between pharmacists and claims professionals is important for both general and injured worker-specific information.
    1. Nursing support
    A more holistic clinical picture of the claim should be obtained by the claims professional. Nurses on an experienced clinical services team are uniquely positioned to assist in explaining the details on medical service claims. Having access to experts in non-drug therapy can allow the claims professional to make more informed decisions.
    1. Claims professional education
    Effective seminars that train and provide guidance to claims professionals on the payor’s policies for managing grey zone medications should be provided. These sessions should be included within claims professional’s regular education and training,
    Summary: Managing medication utilization for injured parties has become increasingly complex for workers compensation payors. As new medications become available, the workforce continues to age and medical histories increase in complexity, navigating the grey zone medication maze will remain a challenge. By putting best practices into place to manage the appropriateness of medications, payors will ultimately ensure injured worker safety while reducing opportunities for fraud, misuse and abuse.
    For more detailed information on the definition and classification of grey zone medications and common grey zone drugs please visit Progressive Medical’s Grey Zone Resource Center.
    Author Tron Emptage, who holds a BS in Pharmacy, is Chief Clinical & Compliance Officer with Progressive Medical. Mr. Emptage has overseen Pharmacy Services, Clinical Services, National Account Management served as Vice President of Strategic Initiatives and Executive Vice President of Business. His 20-year plus experience in pharmaceutical and managed care defines him as a key player in moving the company forward in the arena of national pharmaceutical managed care. Contact him: tron.emptage@progressive-medical.com or 800.777.3574 or visit Progressive Medical.
    About Progressive Medical
    Progressive Medical offers cost management services and programs to the workers compensation industry. By combining its clinical expertise with access to an expansive network of pharmacies, home health care services and medical equipment and supplies, the company enables its clients to manage costs while providing quality care to injured workers. Learn more at Progressive Medical or call 866.939.5365.  http://www.workcomptransformation.com/narcotics-quandary/
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