By: Steve Pratt, CPCU, ARM, CMSP, Senior Vice President of Professional Competence, Gallagher Bassett Services, Inc.
In sports, it takes teamwork to win the game. In workers compensation, teamwork can be an important part of a winning strategy to reduce narcotic use, as different players bring their respective strengths and perspectives to bear on the challenge. Sitting down together, a team of adjusters, nurses and other advisors can develop an individualized game plan to manage the total health and safety of the injured worker. With this approach, the end result should be better overall claim outcomes.
Arming everyone with information
Previously in this space, I talked about the importance of early outreach to healthcare providers and injured workers, either through the pharmacy benefits manager (PBM) or nurse triage program. Such outreach can address therapeutic alternatives and review opioid management with the prescriber and educate the injured worker about the appropriate use of narcotics. Modifying the PBM point-of-sale system to reflect any new regimens allows the adjuster to focus and apply resources only if attention is required on future fills.
I also introduced the concept of a prescription profile mapped to risk ranking based on claimant demographics, prescriber patterns, drug utilization and drug combinations. By providing a global view, the profile gives the adjuster more meaningful information than can be gleaned from a series of individual alerts. This tool is even more valuable when it is used to support a team approach to the claim.
Working together to shape strategy
Since early intervention is key with narcotics, weekly generation and review of prescription profiles makes sense. The team should include adjusters and nurses at minimum, with other advisors—such as a medical director—for more complex cases. At this roundtable discussion, the adjuster can present the regulatory perspective, and the nurse can address the clinical perspective—including the patient’s history, drug use, comorbidities and psychosocial factors that might affect the outcome. The adjuster, as the team captain, should facilitate the discussion. Together, the adjuster and nurse can create a plan that identifies next steps, along with flags that trigger the claim to come back to the roundtable for additional review if the problematic prescribing pattern continues. The team may also decide to initiate an independent medical examination, drug utilization assessment and/or peer-to-peer review.
The adjuster should be responsible for documenting the plan in the claim file and executing the plan. This information can be used for quality control. Random sampling can help ensure that the plans are implemented as intended. Backstops on alerts can help ensure that at-risk cases do not fall off the radar.
How does this approach play out? A case involving concerns about lost or stolen prescriptions and early refill requests, or a lifetime medical benefit claim involving long-term narcotic usage, might open the door to using a peer-to-peer approach for a discussion with the treating physician or to encourage a discussion between the treating physician and the injured worker. When the claims professional is familiar with a given scenario, the roundtable serves to validate the intended plan of action. In other circumstances, when the case involves factors that are out of the adjuster’s experience or expertise, the roundtable can be a powerful strategic planning tool.
Better outcomes overall
This joint process offers a number of benefits. Although claims professionals work within a structure of standard practices, the roundtable approach recognizes that each case has a unique set of facts and is designed to address them. It takes the burden of analysis off the claims professional and by incorporating input from professionals of diverse backgrounds, provides insights that support better-informed decision-making. The end result of the roundtable process is a full claim strategy that addresses the claim from a holistic approach, decreases narcotic usage and delivers appropriate care for the injured worker. As I’ve stated before, if you do the right thing—by managing the patient’s total health and safety—cost containment will follow. Teamwork makes it easier.
About Steve Pratt
Steve Pratt is Senior Vice President of Professional Competence at Gallagher Bassett Services, Inc., where he is responsible for overseeing the technical claim discipline. He has 35 years of experience in the insurance industry, having held senior-level roles in the claims organizations of The Hartford, The Zenith, OBE of the Americas, CNA and Broadspire. Mr. Pratt consulted in the insurance claims environment in quality, reserving, narcotic prescription use and other areas. He also conducts ongoing leadership training in the Ukraine. Mr. Pratt holds a number of professional designations, including Chartered Property Casualty Underwriting (CPCU), Senior Claim Law Associate (SCLA), Certified Medicare Secondary Payer (CMSP), Associates in Underwriting (AU) and Associate in Risk Management (ARM).
About Gallagher Bassett Services, Inc.
Gallagher Bassett Services, Inc., a subsidiary of Arthur J. Gallagher & Co. (NYSE: AJG), is an international risk management services firm headquartered in Itasca, Illinois. GB’s more than 4,500 skilled professionals provide claims management, medical cost containment, analytical and consultative services to its clients worldwide representing virtually every sector of the global economy.