AUSTIN, Texas & SAN JOSE, Calif.–(BUSINESS WIRE)–Now that Texas’ closed formulary rule for treating work-related injuries is in effect, workers’ compensation stakeholders in this state face another more challenging deadline. Before September 1, 2013, providers and insurance carriers must tackle legacy claims involving injured workers dependent on potentially addictive drugs for pain treatment, per rule 134.510.
EK Health Services is helping carriers, employers, employees and medical professionals meet the 2013 deadline with a one-of-a-kind program that helps convert patients to treatment alternatives that are rule-compliant and less costly.
A national leader in medical and disability management services, EK Health has a proven track record with its Next Step Medical Advisory Program℠. The program was developed exclusively by EK Health to resolve stagnating workers’ compensation claims, especially those that are complex, costly and involve poly-pharmacy and potentially addictive pain medication.
Texas’ closed formulary rule, which took affect September 1, 2011, establishes a class of drugs that requires pre-authorization before it can be prescribed. However, the rule provides a different time frame for injuries that occurred on or before September 1, 2011, giving these legacy claims a two-year moratorium before the rule takes effect.
The deferral, ending September 1, 2013, gives providers and carriers time to work together to wean injured workers off drugs that will require pre-authorization. This especially impacts injured workers who are dependent on the “N” class of drugs, as defined by ODG Workers’ Compensation Drug Formulary, for their current treatment protocol. After September 1, 2013, these drugs will require pre-authorization before the prescriptions come up for renewal.
The rule, enacted by the Texas Department of Insurance, Division of Worker’s Compensation (TDI-DWC), requires system participants to be diligent in determining if this class of drugs is medically necessary in the treatment of the injured worker.
The pre-authorization requirement for the legacy claims is no guarantee the carrier can successfully defend a denial of a class “N” drug that was originally approved as medically necessary, as the standard for any medical service provided to injured workers has always been medical necessity. However, carriers can avoid the question altogether if the injured worker can be transitioned to an alternative course of treatment.
Begun over two years ago, Next Step Medical Advisory Program℠ is a collaborative approach utilizing senior EK Health physicians, nurses, legal consultants and project coordinators to provide a comprehensive review and recommendation on the most complicated and costly cases. The team approach is designed to impact a case and move it to closure and settlement.
“We developed the program in direct response to clients who asked for help with claims that plateaued and showed no progress towards return-to-work,” said Todd Brown, practice leader for EK Health and former executive director of Texas Workers’ Compensation Commission (TWCC). “They were paying huge medical costs on cases that had been open for years, and since creating Next Step we have had tremendous success.”
In a real life example, Next Step prevented more aggressive use of opioids and invasive procedures to treat a back injured worker after the Next Step team, assisted by a neurologist, found that the worker’s lower extremity muscle decline was due to a diabetic condition not secondary to the injury. The program saved the insurer enormous sums in medical costs, and the patient was spared needless surgery and escalation of a drug therapy that risked dependency.