Ohio Pharmacy Management Initiatives Save 2.6 Million in Prescription Costs

October 4, 2012 by Leave a Comment

 

Pharmacy Management Initiatives Positive for Injured Workers
 
A recent report to the Ohio Bureau of Workers Compensation (BWC) Board of Directors outlined how the bureau's first ever formulary and a number of other pharmacy management initiatives are helping in efforts to increase positive outcomes for injured workers.
 
 
Narcotics Prescribed Down 1.1 million doses
 
The report includes early data showing a newly enacted formulary has driven down the number of narcotics prescribed to injured workers by 12 percent, or 1.1 million doses, supporting Governor John Kasich's efforts to address the Ohio's opiate epidemic.
 
"Ohio's new formulary is proving an effective way to help manage care and ensure we are getting injured workers the right prescriptions for the right conditions at the right time," said BWC Administrator/CEO Steve Buehrer. "While narcotics can be a legitimate part of the treatment process, we owe it to Ohio's workers to ensure their road to recovery doesn't descend down the dark path of addiction." [WCx]
 
 
$2.6 million Saved in Prescription Costs
 
A review of prescriptions written from February to April 2012, compared to the same period in 2011 showed 1.1 million fewer prescribed doses of narcotics. This equals a 12-percent reduction in the number of doses and a 15-percent, or $2.1 million, reduction in costs. The same review showed the number of skeletal muscle relaxants (SMR) prescriptions dropped by 59 percent, resulting in a 58 percent, or $532,000, decrease in cost. SMRs are among the most commonly overused drug classes and are often prescribed in conjunction with narcotics.
 
BWC began implementing its first ever formulary in September, however, BWC chose to start its study on Feb. 1, the first day that new restrictions on opiates were implemented.
 
The formulary is helping improve the efficiency and effectiveness of treatment, limit the inappropriate use of medications and lower prescription costs. The formulary provides a concise list of medications that can be utilized for treatment of approved conditions related to an injured worker's claim and may include guidelines related to their use.
 
Additional Controls on Pharmacy Program
 
In addition to the formulary, the presentation by BWC Pharmacy Director John Hanna to the Medical Services & Safety Committee late yesterday covered several other controls BWC is placing on its pharmacy program, including:
 
●      Point of service edits that allow BWC's pharmacy benefits manager, SXC Solutions, to screen out prescriptions that aren't related to an injured worker's condition to ensure they are receiving medications relevant to their injury;
●      The standardization of drug utilization reviews, a process that allows for a timely, objective evaluation of prescriptions an injured worker receives to ensure they are appropriate. Drug utilization reviews evaluate the necessity and appropriateness of prescription drug treatment and can identify overuse or dangers mixing of prescriptions;
●      A pharmacy lock-in program that was established to limit the practice of doctor and pharmacy shopping, and the dangers that can arise when medications are prescribed by multiple physicians and are processed in different pharmacies. The program allows BWC, under certain circumstances, to require an injured worker to use a single pharmacy for non-emergent prescriptions. BWC can also restrict an injured worker convicted of a drug offense to the use of a single prescribing physician in order to receive reimbursement for non-emergent prescriptions;
●      Requiring generic medications when available.
 
"By better understanding and managing the role of pharmaceuticals in recovery, we are helping injured workers heal and get back on the job sooner," said Buehrer. "The added benefit is the cost savings that help us keep premiums affordable for Ohio's businesses." [WCx]
 
 

Author Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com.  Contact:  mstack@reduceyourworkerscomp.com. 

 

 


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©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

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Maximize the Value of Your Pharmacy Benefits Manager

October 1, 2012 by Leave a Comment

 

PBMs Can Be More Than Discounted Prescriptions
 
Insurers and self-insured employers often utilize Pharmacy Benefit Managers (PBM) to manage the cost of prescription medications in their workers’ compensation claims.  The contracts that PBMs have with the national drug store chains reduce the cost of each individual prescription given to an injured employee. Unfortunately, that is where many insurers and self-insured employers stop utilizing their PBM.  Often more, or even much more, can be done by insurers and self-insured employers to control the cost of medications.
 
 
Most Doctors Disconnected From Cost of Workers Comp Claim
 
Most doctors treating injured employees have little or no direct contact with the employers and adjusters handling the workers’ compensation claim.  The doctor’s office staff will handle all telephone calls, emails or faxes from employers, nurse case managers or adjusters. The limited contact the doctors have with anyone besides the employee will be brief discussions with the nurse case manager. For the most part, doctors work absent of any input from other parties involved in the workers’ compensation claim and are oblivious to the cost control activities on the claim.
 
The goal of the treating doctor is to assist the injured employee in regaining as much functionality as possible.  The treating doctor will normally prescribe all necessary diagnostic testing, medical treatment and medications without concern for the cost. 
 
 
Lack of Involvement Leads to Higher Costs
 
This lack of involvement in the cost of medications often leads the doctor to make medication choices that cost more, but are no more beneficial to the injured employee than alternative choices.  For instance – doctors will often write a prescription with the notation “DAW”.   DAW stands for ‘dispense as written’ which tells the pharmacist not to substitute a generic drug for the name brand drug.   As many drugs have a generic version that is biochemically and therapeutically equivalent, the DAW adds additional cost to the prescription, but does not provide any additional benefit to the injured employee.
 
The PBM should contact the medical provider’s office and inquire why the DAW is needed when there is a generic equivalent.  If your PBM is not doing this when the medical provider writes the prescription for the name brand drug, you should request they start doing so.  Also, a follow up letter should be sent by the PBM to the medical provider asking for all future prescriptions to be for the generic version of the medication.  If your PBM is not doing this, again you should request they do so.
 
 
PBM Should Push for Generics
 
If the medical provider continues to write prescriptions for the name-brand drugs when generic equivalents are available, a Letter of Medical Necessity should be generated by the PBM and sent to the medical provider before the PBM authorizes the pharmacist to dispense the medication.  The Letter of Medical Necessity will ask the doctor to provide documentation as to why the name brand drug must be used and not the generic equivalent.  Often there is no reason for the name brand drug other than that is what the doctor has always prescribed for the particular medical need.  When the doctor has to respond to the Letter of Medical Necessity, the prescription usually gets changed to the generic version.  This is not to say that there are no situations where the name brand drug is a better option.  The Letter of Medical Necessity does not dispute the use of the name brand drug, but does ask why.
 
If neither an inquiry as to why a prescription is written as DAW nor a Letter of Medical Necessity changes the behavior of the treating doctor, the employer, nurse case manager or adjuster should request a Peer-to-Peer Review, which may make a difference. 
 
 
Your PBM Should Have Medical Opinion to Review All Prescriptions
 
Your PBM should have on-staff, or at least on retainer, a doctor who can discuss with the treating doctor the reason a particular prescription is being written (especially with narcotics and other medications which are utilized on a long-term basis).  The treating doctor may have a valid reason why the more expensive (or most expensive) option is necessary.  The Peer-to-Peer Review will frequently result in the treating doctor recognizing that cost is a factor in the medical treatment, resulting in the treating doctor writing prescriptions that provide the needed medical care while controlling cost.
 
We recommend you confirm with your PBM they are questioning all DAW prescriptions, sending a letter to the doctor asking for future prescriptions to be generic, sending a Letter of Medical Necessity when generics are not used, and utilizing Peer-to-Peer Reviews when needed to control the cost of medications.
 
 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.

 

Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com.  Contact:  mstack@reduceyourworkerscomp.com. 

 


WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com

VIEW SAMPLES PAGES

MODIFIED DUTY CALCULATOR:  www.LowerWC.com/transitional-duty-cost-calculator.php

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

Filed Under: Insurance Issues, Rates, Premiums, Medical Cost Containment Tagged With: , , ,

Pharmacy Lock-in Program Designed to Assist Injured Workers

March 15, 2012 by Leave a Comment

Ohio Bureau of Workers Compensation (BWC) Administrator/CEO Steve Buehrer late last month unveiled new measures to improve the safety of medication prescribed to Ohioans recovering from workplace injuries and limit the practice of doctor and pharmacy shopping.

 
 
The Coordinated Services Program is designed to limit the dangers that can arise when medications are prescribed by multiple physicians and are processed in different pharmacies.
 
"There is a point at which prescribed medications move from being a useful and necessary part of a treatment plan to hindering an injured workers' recovery and return to work," said Buehrer. "Identifying where prescriptions are being used in a manner other than medically necessary will set the injured worker on a better path to recovery. It will also assist in our return-to-work effort at BWC by addressing an issue that keeps claims lingering in our system longer than they should."
 
 
The program allows BWC, under certain circumstances, to restrict an injured worker to the use of a single pharmacy for non-emergent prescriptions. The injured worker selects the pharmacy from a list of eligible pharmacies. BWC can also restrict an injured worker convicted of a drug offense to the use of a single prescribing physician, selected by the injured worker from BWC certified physicians, in order to receive reimbursement for non-emergent prescriptions.
 
 
The lock-in program is among several recent improvements made to BWC's pharmacy program, including BWC's first ever outpatient prescription drug formulary, which became effective in September. The industry-standard formulary focuses on the well-being of the injured worker by allowing for a thorough clinical review of each new medication, better monitoring and control of inappropriate use. The formulary is expected to save up to $15 million by the end of 2012.
 
 
BWC is also now requiring, with physician approval, generic medications when available and has established a Pharmacy and Therapeutics Committee comprised of practicing pharmacists and physicians to advise BWC leadership on issues related to the use of medications prescribed to treat injured workers.
 
 

The committee is also conducting relatedness editing to ensure injured workers are receiving medications.

Author Robert Elliott, executive vice president, Amaxx Risk Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He is an editor and contributor to Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: Info@ReduceYourWorkersComp.com.
 
 
WORKERS COMP MANAGEMENT GUIDEBOOK:  www.WCManual.com
WORK COMP CALCULATOR:  www.LowerWC.com/calculator.php
 
 
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
Filed Under: Medical Issues, Wellness Programs and Workers Compensation Tagged With: , , ,

5 Ways a Pharmacy Benefit Manager can Control Prescription Costs

January 9, 2012 by Leave a Comment
 
 
The cost of prescribed drugs, especially narcotic pain medications, is rising in the world of workers' compensation. This cost increase is due to the fact that a drug company is like any other company: When the demand for your product is high, supply lessens, and costs have to increase. And, these medications are not exactly cheap to manufacture. In fact I saw a news report that some cancer fighting drugs are in short supply due to overwhelming demand.
 
 
Think about going to your personal physician for a knee strain you had over the weekend playing football with your family. You probably went to your doctor, and you probably left with a prescription for Motrin buddied up with a short-term prescription for a narcotic pain reliever — even if a cold pack or hot pack and rest would have taken care of the problem. This is the world in which we live. In the past, these pain medications were for extremely acute trauma, such as a car accident or bone fracture. But more and more, medications such as Vicodin, Percocet, Oxycodone, etc are being prescribed for the slightly-above-average diagnosis of lumbar or shoulder strain. (WCxKit)
 
 
Below we discuss five ways you can try to control these associated drug costs when it comes to your workers compensation claims. By no means is this an exact science, but it is certainly one you should look into for help controlling your bottom line.
 
1. Come up with your game plan.

Whether you have five claims a year, or five claims per week, medication cost will be a significant expense of the claim. Many carrier/TPAs are partnering with a Pharmacy Benefit Manager (PBM) to review prescription history and also to provide a reduced cost for medications. These outside vendors attract carrier/TPAs by offering them a discount cost for medications, in exchange for their guaranteed business.

 

Adjusters set claimants up with a drug card from these vendors, and they are widely accepted at many pharmacies nationwide. Furthermore, the PBM will review the injury and the claimant’s individual medication history. They can recommend medications based on the injury type and location. This is an attempt to stop every John Doe back pain sufferer from walking out of his doctor’s office with an RX for Percocet, when he really does not meet the criteria for needing that strong of a medication to begin with. Most strains can resolve by taking a stronger dose of Motrin, an anti-inflammatory medication similar to Advil or Ibuprofen. The PBM will also monitor duration of medication use and quantity limits. Why pay for 90 pills when John Doe should only need 30? Medication costs are associated with dosage as well, so it doesn’t make sense to pay for 90 pills unless they are needed.

 

2.  Start being aggressive at the first prescribed RX.

When a new claim is filed and the adjuster sets the drug card up to be mailed out to the employee, it may already be too late. This is when proper communication is handy. If you have a worse-than-average claim, you can phone your adjuster with the info, and they can get the PBM info right to the claimant.

 

This way they are not getting medication from an occupational clinic or hospital, where the costs are typically the highest. Right off the bat they can use the PBM card, and that reduces cost right from the beginning. This also helps manage future spending on RXs, since they already have the card and should be using it for any medication the claimant is prescribed. Sure, not using the card for your first medication fill is no big deal if you only have one or two claims per year, but if you have one or two claims per week, over the course of a year this can lead to a dramatic savings in medication cost. Every little bit of savings will help in the long run, and it is important not to overlook the small savings that you can implement right away.

 

3. Can you do bulk home delivery?

For those injuries lasting longer than a month, it is worth it to look into home delivery of medications. This increases the discount, because you buy more of the medication at one time, and you do not have to pay the pharmacy overhead for a short-term 30 day fill. Injured workers will appreciate having one less errand to run, especially those who do not have easy transportation readily at hand. At the same point, the PBM will monitor dosage and quantity. Why should you continue to get a medication if it is not helping? Or, if the injured worker is not taking the medication at all? These are leakage costs, and expensive ones at that. The adjuster will ultimately decide if a claim is worthy of needing home delivery, and the delivery will not last forever. If a person has a bad fracture and will need a long-term supply of Motrin, this is a perfect scenario.

 

Adjusters do frown on home delivery of narcotic pain meds. This gives the claimant a large supply of potentially strong medication, which carries the risk of addiction. Home delivery meds are generally milder. Again, even though these drugs may not cost the most, any sort of savings is better than no savings at all.

 

4. Are you using prescription utilization review?

PBM companies use a panel of clinical pharmacists to examine prescription data and injury type to make sure appropriate medication is dispensed. This helps control unnecessary costs due to prescribing incorrect medication. Also, PBM utilization review will help to control fraud by monitoring the date and location of refills. Red flags indicating abuse include early refills, a doctor shopping around to get new prescriptions, or a patient changing pharmacies to get refills. Clinical pharmacists also are useful at catching new medication trends, proper quantities of medications, and future costs/needs for ongoing medications. 
 
By using prospective utilization review, done before the product is used, to avoid the cost, consider prior authorization program. By having an MD on the TPA's staff review the file, many of the medication concerns are addressed proactively. The utilization review company you use, should be URAC certified to ensure quality, credentials and training. A good TPA might even have a chronic pain program to discuss pain issues with an interdisciplinary team of experts. 
 
 
 
 
5. Use a Pharmacy Benefit Manager or vendor to help with repeat offenders and duplicate prescription medications.
 
This use of an outside PBM is effective for many reasons, including catching a doctor prescribing both a short-term and long-term narcotic pain medication, duplicate or similar prescriptions being unnecessarily prescribed, and implementing the use of generics whenever possible. The PBM will also participate in state-wide reporting, which will catch if a claimant has other narcotic pain medication fills before the date of injury. This can show the worker may have a history of requesting certain narcotics — a red flag for abuse.
 
 
Surveillance companies usually have a service that can do a background check of pharmacies, to see if your claimant has had fills of certain medications aside from the meds needed for your specific injury. This fights fraud, and can expose someone that may have a prescription drug problem. An easy way to get strong medication is to file a comp claim, and any weapons you have to fight fraudulent claims are worth it.(WCxKit)
 
 
In summary, a third-party PBM is a useful tool not only for cost-savings but also for catching the many forms of prescription abuse out there. Doctors get lazy when it comes to prescribing medications. Sometimes the answer to every injury is a prescription of Vicodin, Percocet, or some other narcotic when none are needed. Not only are these medications expensive, but they can carry long-term health problems including addiction, which only increase the overall cost of the claim. Using a PBM is another way of being proactive when it comes to handling your claims, and your carrier/TPA will have more information on what you can do to implement a PBM program for use on all of your claims that require prescription medication.
 

Ask your TPA what programs they offer.
 


Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com. Contact: RShafer@ReduceYourWorkersComp.com.
 
 

Our WORKERS COMP BOOK:  www.WCManual.com
 
WORK COMP CALCULATOR:  www.LowerWC.com/calculator.php

 
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
Filed Under: Coordinating Medical Care, Drug, Alcohol & Impairment Testing, Medical Cost Containment Tagged With: , , , ,

Pharmacy Benefits Management Cost Control Tips

December 7, 2011 by Leave a Comment

Often overlooked in the on-going battle to control workers compensation cost is the cost of prescriptions. Pharmacy Benefits Managers (PBM) offer the self-insured employer, insurer or third party administrator a way to manage and control the cost of drugs. While PBM provide a cost savings by obtaining a discount on the cost of drugs, the good PBM goes a lot further.

 

 

The PBM that will provide the best results is the one that keeps track of not only the cost savings provided, but also the utilization of prescriptions, especially narcotics. The better PBMs will alert the medical provider and adjuster when there is over-utilization of drugs. (WCxKit)

 

 

The PBM you select should have a national network covering most of the 70,000+ drug stores in the United States. The PBM should have a working relationship with the three major drug store chains which include CVS, Walgreens and Rite-Aid, as well as the local independent drug stores.

 

 

The effectiveness of the PBM can be judged by three different criteria which are  the rate of use by the employees, the ease of use for the adjuster, and their technology interface ability.

 

 

The penetration rate is a measure of how extensively the employees use the pharmacy program. The PBM will often mail the employee a pharmacy benefit card with a cover letter on the pharmacy benefit card use.  Most employees will opt to use the PBM card rather than out of pocket and then having to seek reimbursement. The adjuster should have the ability to suspend the use of pharmacy benefit card when the claim is denied or concluded.

 

 

The PBM should coordinate the prescription with the employee, the pharmacy and the medical provider without involvement of the adjuster. The easier the process is to use, the less the involvement of the adjuster. The better PBM will make the process totally seamless resulting in no involvement for the adjuster, while the adjuster can be assured the cost of the prescriptions and the utilization of the prescriptions is being properly controlled.

 

 

The PBM should provide the user of the service with the ability to review on-line all transactions and to obtain all necessary management reports. The technology interface should allow you to quickly know and understand the prescription drug usage of any employee. This will allow you to identify both the high cost employees and the doctors who prescribe the medications.

 

 

There are numerous ways the PBM can control cost.  Some of the techniques used by PBMs include:      (WCxKit)

 

-The use of generic drugs wherever substitution for patent drugs is permitted.

-A comprehensive, standard formulary specific to workers compensation injuries.

-A pre-negotiated price for each drug in the formulary.

-The ability to provide home delivery for employees who are unable to pick-up the prescribed drugs.

-Mail order services for maintenance drugs.

-The ability to approve or deny the “off-label” use of a drug.

-The ability to prevent consumption of drugs faster than manufacturer recommendations.

-The prevention of multiple, overlapping prescriptions from multiple doctors.

-The prevention of multiple pharmacies filling the same prescription.

-The prevention of filling non-injury related prescriptions.

 

 

The use of a PBM is a great way to reduce the cost of prescriptions and to lower their cost impact on your workers compensation program. To learn more about PBMs and how you can utilize their services to reduce your workers compensation cost, read the chapter on Implementing a Pharmacy Benefits Management Program in our new 2012 edition of Manage Your Workers Compensation Program, Reduce Costs 20-50%. To obtain your copy, please contact us.

 

 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com. Contact: RShafer@ReduceYourWorkersComp.com.

 

 

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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact

Info@ReduceYourWorkersComp.com.

 

Filed Under: Medical Cost Containment, Medical Issues Tagged With: , , ,

Eight GREAT Techniques to Control Workers Compensation Medical Costs

November 15, 2011 by Leave a Comment
The cost of medical care is the largest part of the total cost of workers compensation. Finding ways to control and manage these medical costs is important to maintain and control workers compensation cost. There are numerous techniques to use to control medical costs.
 
Let us look at the ones providing the most benefit to the employer:
 
 
1. Nurse Case Managers
The most important person in the control of workers comp medical costs is the Nurse Case Manager (NCM). The NCM is responsible for planning and coordinating medical care to assist the employee in returning to work as soon as physically able or when the employee reaches the maximum medical improvement (MMI). The NCM role can either be in the office handling most communications by telephone — a telephonic case manager (TCM); or the nurse can spend most of her (or his) time away from the office — a field case manager (FCM) who attends medical appointments with the injured employee.   (WCxKit)
 
 
Whether the nurse is referred to as a NCM, TCM, or FCM, the role is to make sure the employee receives all necessary medical care as quickly as possible. The responsibilities of the NCM include:
 

1.      Consulting with the medical providers on the best options for treating the employee.

2.      Coordinating the medical care between the different medical providers.

3.      Preventing the over utilization of medical care while ensuring the employee receives all needed care.

4.      Acting as a liaison between the employee, employer, physician, therapist, insurer, and other parties.

5.      Facilitating the communications between the employee, employer, and adjuster.

6.      Arranging the employee's return to work either in modified duty with the necessary accommodations or full duty without any accommodations.

7.      Keeping the adjuster and employer informed as to the employee's medical status.

 
2. Medical Provider Networks
When various medical providers including doctors, hospitals, physical therapists, and others join together for the purpose of providing medical care to a specific group (employees), a medical provider network is formed. In exchange for sending all injured employees to the medical provider network, the employers or insurers receive a group discount on the cost of medical care. California and Texas are the two biggest states where medical provider networks are utilized to control the cost of workers compensation. Follow the rules exactly, and you can direct care for the life of the claim in California. In California, these are called MPNs.
 
 
3. Medical Triage
Medical triage is the process of having a trained nurse arrange the medical care for any employee who reports an injury. The triage nurse coordinates the medical care for the employee, arranges for the initial medical visit and any follow up visit, and advises the adjuster on the nature of the injury and the type of initial care received by the employee. Approximately 40% of your claims will be "self care" claims, which means you'll have 40% fewer claims, many of which would have ultimately become lost time claims. It's a way to stay on the claim from Day 1. Nurse triage can even direct the employee (and supervisor) to the nearest PPO in your network – if allowed by state law.
 
 
4. Utilization Reviews
Utilization review is the review of medical care by another party other than the medical provider to ensure the appropriateness of the medical care. There are three types of utilization review.
 

1.      Pre-certification: the requested medical service whether hospitalization, surgery or diagnostic testing, is reviewed by a trained nurse or doctor, to verify it is the best medical approach for the injured employee's medical care, before the medical care is provided.

2.      Concurrent reviews: occurs when the employee is in the hospital is having any other medical care that takes enough time for the medical necessity to be checked before it is completed.

3.      Retrospective reviews: verifies the need for medical services already provided.

 
 
5. Medical Fee Schedules
In an effort to control medical costs, most states place a dollar cap on each type of medical service an employee can receive following an injury. A medical bill review company compares all medical bills submitted against the fee schedule to insure only appropriate services are billed and billed for the correct amount. Most states have their own fee schedules – which is generally a very large, complex list (like a phone book) of codes for each injury/illness and treatment.
 
 
6. Pharmacy Benefit Managers
Pharmacy benefit managers (PBM) specialize in providing the employee with needed prescription medications. The PBM arranges for the employee to obtain prescriptions at drug stores within the network, or provides to the employee, by mail, any maintenance medications the employee will take over an extended period of time. PBMs can help control the overuse of prescription medication and curb opioid abuse.
 
 
7. Medical Panels
Several states allow the employer to designate a list of medical providers the employee can select from when the employee is injured. This panel of doctors includes a variety of medical specialties and/or medical facilities. The medical panel is normally posted at the employee's work site for the employee to chose from. This is sort of a blend between employee selects their own provider and employer selects the provider. Which ever state/s you are in make sure you know how medical provider selection is done.
 
 
8. Independent Medical Evaluations (IME)
An independent medical examination is a second opinion from a doctor selected by the insurance company to confirm the diagnosis and treatment of the employee. It can also be used to verify the disability or impairment of an employee when the employee finishes medical care. (WCxKit)  Have an MD write the IME cover letter and point out to the IME doctor relevant causation issues and/or mechanism of injury issues that make be disproportionate to the injury. Why get an IME if it's not going to be preceded/set up with an effective cover letter?
 
 
These 8 approaches are not the only ways to control medical costs in your workers compensation claims. There are various other techniques that can be used to limit medical costs and additional approaches are being developed as more and more employers look for ways to control these costs.
 

Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com or 860-553-6604.
 
 
ABC's of Workers Compensation Cost Containment Book: www.WCManual.com
 
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Filed Under: Claim Management, Medical Cost Containment, Medical Issues Tagged With: , , , , ,

Texas Pharmacy Formulary Webinar Looks at New Rules

August 11, 2011 by Leave a Comment
 
Texas often leads the nation in workers compensation cost containment and narcotics legislation. The state recently continued their history of reform by adopting a new pharmaceutical formulary that will reduce the amount of money spent on workers compensation medications and improve the overall health of the state's employees. How does it work? What can you do to remain in compliance?
 
 
Broadspire is conducting a webinar to provide answers about the new Texas formulary  August 23. Speaking on compliance issues was formulary co-creator Ralph Kendall, PharmD., vice president of clinical services at Healthesystems. 
 
 
Also Jacob Lazarovic, MD, chief medical officer at Broadspire, will discuss the clinical implications of the formulary and Lynn Sergeant, RN, team manager of utilization management at Broadspire, will be discussing how Broadspire is operationally responding to the formulary.
 
 
For 4 p.m. Aug. 23, either click the following link or copy and paste it into your Web browser:
 
 

For help or support go to https://crawfordandcompany.webex.com/crawfordandcompany/mc click “assistance,” then click “help” or “support.”


Our WC Book:  http://www.wcmanual.com
WORK COMP CALCULATOR: http://www.LowerWC.com/calculator.php
 
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Filed Under: Coordinating Medical Care, Implementation and Rolling Out Your Program, Insurance Issues, Rates, Premiums Tagged With: , , ,

Florida’s Physician Dispensing Found to Drive Workers Comp Costs Higher

July 24, 2011 by Leave a Comment

img1The Workers Compensation Research Institute (WCRI) reports this week in Prescription Benchmarks for Florida – 2nd Edition that physician dispensing is driving up prescription costs in Florida.

 

 

The study looked at the costs, prices, and distribution of drugs in the state and took a closer look at doctors dispensing medicine there. Findings showed the average payment per claim for prescription drugs in Florida’s workers compensation system was $536. This is 45 percent higher than the median of the states in the study making it number two out of 17 states. The last two years of the study showed an increase of 14 percent in average cost per claim though they were stable in other states in the study.

 

 

Legislation regarding physician dispensing was vetoed in 2010. Advocates of physician dispensing say it saves money because doctors are more likely to prescribe generics. Advocates also say that patient compliance, and, therefore, positive outcomes are more likely when doctors are doing the drug dispensing.

 

 

But the study showed this was not the case – generics were prescribed equally from both doctors and pharmacies. Further, even when using generics, the cost per pill was higher at the doctor’s office.

 

 

Higher and growing costs of prescription drugs in Florida were largely due to more frequent and higher-priced physician dispensing, the study indicates. “Physician-dispensing in Florida’s workers’ compensation system has been taking an increasingly larger share of prescription payments. The percentage of prescription payments for physician-dispensed prescriptions in Florida increased from 17 to 46 percent over a four year period,” according to the WCRI report.

 

WCRI’s 17-state study also provides some evidence that helps address concerns about legislation (H.B. 5603), passed in 2010, but later vetoed, that would limit reimbursement rates for physician-dispensed prescriptions to the same level as pharmacies for the same medications.

 

 

Other findings include:

  1. Physician-dispensers received 46 percent of prescription payments in the state.
  2. Average price paid to Florida pharmacies increased by 3 percent over the course of the study.
  3. California passed legislation regulating doctor dispensing and saw a large drop in cost per pill of physician-prescribed muscle relaxants. And physicians prescribed more non-repackaged drugs.

 

 

The 17 states included in this study are California, Florida, Illinois, Indiana, Iowa, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, New Jersey, New York, North Carolina, Pennsylvania, Tennessee, Texas, and Wisconsin.(WCxKit)

 

 

WCRI is based in Cambridge, MA and is a nonpartisan, not-for-profit membership organization supported in its public policy research by employers, insurers, insurance regulators and state regulatory agencies, as well as several state labor organizations.


Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information.
Contact: RShafer@ReduceYourWorkersComp.com.

 

Our WC Book:  http://www.wcmanual.com

WORK COMP CALCULATOR: http://www.LowerWC.com/calculator.php

MODIFIED DUTY CALCULATOR:  http://www.LowerWC.com/transitional-duty-cost-calculator.php

WC GROUP: http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

 

Filed Under: Assessment & Diagnostics, Medical Cost Containment Tagged With: , , , ,

Seminars on Texas Pharmacy Formulary and Claims/eBill

July 19, 2011 by Leave a Comment

pic6The Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) will present a series of free, half-day educational seminars titled Pharmacy Closed Formulary and Clean Claims/eBill. The seminars are being offered in cooperation with Small Business Development Centers.

 

 

The Pharmacy Closed Formulary portion of the seminar will provide an overview of the pharmacy closed formulary rules adopted by the TDI-DWC in December 2010 for both certified network and non-network workers’ compensation claims with dates of injury on or after Sept. 1, 2011.

 

 

The Clean Claims/eBill portion of the seminar will provide an overview of the new TDI-DWC requirements related to submitting paper and electronic medical bills, including a discussion of the changes from the previous requirements and a brief introduction to the new electronic medical billing standards. This presentation also provides an opportunity for new and experienced medical billing employees to recognize how to complete medical bills to minimize insurance carrier returns or rejections after the Aug. 1, 2011 effective date.(WCxKit)

 

House bill 528, which becomes effective June 17, can be found here.

 

Among some the regulations in the bill include:

  1. Insurance carriers must reimburse health care providers in accordance with the TDI-DWC’s pharmacy fee guideline or at a contracted rate.
  2. Insurance carriers may also reimburse health care providers for pharmaceutical services at rates inconsistent with the TDI-DWC’s pharmacy fee guideline if the carrier has a contract with that health care provider that includes a specific fee schedule.
  3. Insurance carriers or their authorized agents may use a pharmacy informal or voluntary network to obtain these contractual agreements with health care providers. If an insurance carrier chooses to use a pharmacy informal or voluntary network, there must be: a contractual arrangement between the insurance carrier or its agent and the pharmacy informal or voluntary network authorizing the network to contract with health care providers for pharmaceuticals on the insurance carrier’s behalf; and a contract between the network and the health care providers that includes a specific fee schedule and complies with the health care provider notice requirements of Texas Labor code.
  4. The carrier must notify each health care provider, at least quarterly of any person, other than the injured employee, to which the network’s contractual fee arrangements with the health care providers are sold, leased, transferred or conveyed.
  5. Each informal or voluntary network that has contracts in effect on June 17, 2011, must report the information listed in the labor code by July 17, 2011.
  6. Failure for a pharmacy informal or voluntary network to comply with the registration requirements will result in an administrative violation.

 

Details of these new requirements will be explained at the conference.

 

Due to limited space, registration is required. For more details on the following educational seminars, visit the TDI-DWC Events and Training Calendar at www.tdi.state.tx.us/wc/events/index.html. Pharmacy Closed Formulary will be presented from 8 a.m. to 11 a.m. and Clean Claims/eBill will be presented from 11 a.m. to 12 p.m. at each venue. Texas workers’ compensation system participants may attend one or both portions of the seminar.

 

 

Training Dates

Date                       City

May 6, 2011          Dallas

May 7, 2011          Fort Worth

May 20, 2011        San Antonio

May 25, 2011        Wichita Falls

June 3, 2011        Corpus Christi

June 8, 2011        San Antonio

June 10, 2011      Houston

June 24, 2011      Edinburg

July 15, 2011        El Paso

Aug. 18, 2011       Austin

 

 

This information was provided by attorney Stuart Colburn, a Shareholder at Downs Stanford in Austin, Texas. Colburn has extensive experience in all phases of dispute resolution before the Texas Department of Insurance, Division of Workers Compensation and in district courts across the state. Stuart represents clients regarding workers compensation, non-subscription, subrogation, and bad faith litigation. He is the founder and the first chairman of the State Bar of Texas (SBOT) Workers Compensation Section; course coordinator for the SBOT the Advanced Workers Compensation Seminar; and course coordinator for the Texas Workers Compensation Forum. He can be reached at:  scolburn@downsstanford.com

 

Filed Under: Legal Doctrines, Professional Development Issues, Seminars and Courses Tagged With: , ,

WCRI Identifies Policies to Hold Down Pharmacy Costs

July 14, 2011 by Leave a Comment

pic1Why are prescription costs up to 40 percent lower in Washington state than average?

 

 

According to the Workers Compensation Research Institute (WCRI), the northwestern state implemented policies that kept these costs down.

 

 

“Prescription Benchmarks for Washington,” points to these four tools:

  1. A formulary of approved drugs and therapeutic interchange.
  2. Lower-than-typical pharmacy fee schedule.
  3. Mandatory generic substitution.
  4. Infrequent physician dispensing.

 

 

In the study, WCRI looked at 17 other states and found “a wealth of detailed price and utilization statistics that may be useful when debating such issues as: pharmacy fee schedules, physician prescribing patterns, medical cost drivers, and laws that mandate the use of generics.” Other states included in the study were: California, Florida, Illinois, Indiana, Iowa, Louisiana, Massachusetts, Maryland, Michigan, Minnesota, New Jersey, New York, North Carolina, Pennsylvania, Tennessee, Texas, and Wisconsin.

 

 

 

“There may be some important lessons for policy makers in other states from the regulatory approaches used by Washington State,” said Dr. Richard A. Victor, WCRI’s executive director.

 

 

Other findings include:

  1. The average prescription cost per claim in Washington was 40 percent lower than the median of the 17 states in the second edition of the WCRI prescription benchmarks—after adjusting for the longer claim duration. Without this duration adjustment, the average prescription cost per claim was 11 percent lower than the 17-state median.
  2. The average price per pill paid to Washington pharmacies was 35 percent lower than the median state as a result of state policies and programs, such as: a formulary of approved drugs and therapeutic interchange, lower than typical pharmacy fee schedule, and mandatory generic substitution. (WCxKit)
  3. Physicians in Washington more often prescribed stronger, Schedule II narcotics, compared to physicians in the other study states.

 

 

More information on this study, available for purchase, can be found here.


Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.

 


Our WC Book: http://corner.advisen.com/partners_wctoolkit_book.html

WORK COMP CALCULATOR: http://www.LowerWC.com/calculator.php

MODIFIED DUTY CALCULATOR:  http://www.LowerWC.com/transitional-duty-cost-calculator.php

WC GROUP: http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

 

Filed Under: Assessment & Diagnostics, Safety and Loss Control Tagged With: , , ,
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