By Joe Paduda, Author, Managed Care Matters
Last week we discussed the coming crisis in workers comp – the impact of opioids on disability duration, claim costs, and reserves. It is my contention that most insurers, rating agencies, and actuaries have not yet fully grasped the impact opioids will have.
When they do, execs will be demanding solutions, and fast. Those solutions are the subject of this column.
Fact is, the claim management process has not kept up with changes in prescribing patterns and the implications thereof. Common “best practices’ in workers’ compensation claims management do not address the impact of opioids; not in file strategies, file disposition, legal management, or other components of the process. Here are a few ideas, and a suggested “best practice”, payers can use to develop their own approach.
While there are two distinct types of claimants, those that just began using opioids and those that have been incurring bills for opioids for years, there is a common process based on an incremental approach. For both claim types, the claims professional moves to the next level of intervention if necessary.
The process is triggered by the PBM, which sends an alert for initial opioid prescriptions or a significant change in the dosage, or when opioid usage exceeds 120 morphine equivalents for 6 months. The alert goes to the claim file/claim adjuster, by appropriate mechanism (email, FTP site, integrated claims feed).
- Triage by diagnosis – no alert for catastrophic claims or other diagnoses where the use of opioids appears to be consistent with evidence-based clinical guidelines (e.g. end-stage cancer)
- Part of overall alert process/triggers
- Alert includes key data, e.g., opioid use at 30/60/90 days, 120 morphine equivalent doses (MEDs) or greater, initial script for diagnoses where opioid usage is not indicated.
Initial Physician Contact
The claims professional or nurse case manager contacts the physician to discuss treatment plan including:
- Tapering plan – Develop monitoring and follow up process to track tapering.
- Functional improvement assessment
- Opioid agreement, agreed to and signed by claimant – If appropriate, send prescribing physician a sample opioid agreement and best practices for opioid treatment.
- Random urine drug testing (initial test pre-prescribing followed by random tests consistent with clinical guidelines)
- Screening for addiction/dependency
- Screening for depression
- Ongoing assessment of pain mitigation
Drug Utilization Review
- If prescription falls outside guidelines, claim handler/case manager then requests a Drug Utilization Review by the PBM or DUR partner.
- PBM/DUR partner evaluates the claim and claimant, contacts the prescribing physician to discuss their findings and recommendations.
- If script fails DUR and/or prescribing physician refuses to respond/comply, refer to physician for follow up with prescribing physician
Conduct a Peer-to-Peer Review
- Provide reviewer with all prior claim medical information, opioid related data (DUR, alert info, etc.)
- Reviewer contacts the prescribing physician, reaches agreement on treatment plans if at all possible
- Follow and monitor the agreements established
- If peer review does not result in altered treatment plan, move to claimant evaluation
Conduct a claimant evaluation
- Locate an Addictionologist to assess the claimant for risk of addiction/dependency, if necessary schedule this as an IME.
- Follow with the injured worker, his/her attorney and others to implement the recommendations
- If the information is contested, consider a formal hearing to deal with the issue
Decision Point if MD Is Uncooperative
- Claim handler, medical support staff, and defense counsel develop strategy
- If appropriate, provide defense counsel with the evidence based information, which is the basis for the need to taper/risk of addiction/results of drug test indicating possible diversion that was provided to the physician
- Request defense counsel contact plaintiff counsel for the injured worker (if appropriate) to explain the desire is not to terminate benefits, but to assist the injured worker in recovery process.
There are no silver bullets. Each state is different, each claimant is different, some providers are impossible to deal with, and there’s no question administrative law judges can and do have a big impact on claims handling.
Payers can either complain about the unfairness of it all, how hard it is, the difficulties inherent in handling claims, the recalcitrance of the claimant, how awful the claimant’s attorney is, the claimant-friendly judge and on and on.
Or they can stop ignoring the problem and get to work developing creative and assertive approaches to opioids.
About Health Strategy Associates
Health Strategy Associates is a national consulting firm specializing in managed care for workers’ compensation and group health. The firm serves insurers, managed care companies, employers, health care providers, and venture capitalists.
Developing a successful managed care program is like mastering chess, a game in which a series of decisive, logical moves – driven by analysis, research and insight – lead to victory. By constantly monitoring the world of health care and the macro factors and policies influencing it, we help clients make informed and intelligent decisions.
Principal Joseph Paduda has an unrestricted view of the national market and its players and an uncanny ability to take a big-picture view and drill down into the smallest niches. His advice will help you summon the full force of your resources to create better products, stronger market share and greater profits.