By Michele Settel, Vice President, Workers’ Compensation Division, Cordant Health Solutions
A drug test is a valuable tool that can be used to identify whether a claimant is adhering to their medication regimen as prescribed. The purpose of drug testing is not to “catch” those who are not taking their medications. The primary goal is promoting compliance to ensure the safety and effectiveness of an injured worker’s drug treatment plan. One of the most common questions I receive from our clients is, “What should I do when a drug test yields an inconsistent result suggesting non-compliance?”
Every provider, adjuster and case manager would be glad to see injured workers follow their treatment plan diligently, but the truth is that every claim and patient with his or her own unique medical condition requires a different plan of action. However, there are some general steps a payer can take when a lab report yields unexpected results.
Obtain Clinical Support
If you have access to nursing or case management services within your organization or as a partner, escalate. Case managers offer clinical knowledge and support to facilitate a detailed and necessary conversation with the treating provider. An effective case manager will interact directly with the treating provider and the injured worker to develop an action plan that may include a review of the prescribed medications and steps to improve adherence.
There are other common scenarios in which a case management assignment can be beneficial if a case manager is not already assigned to the claim:
- A claimant receives an initial inconsistent test result, but does not have another visit to a healthcare provider scheduled until months later, if at all. While the adjuster or case manager can schedule an appointment, the case manager can take this opportunity to assess compliance with the provider’s treatment plan and reinforce compliance with the injured worker.
- A claimant has received two inconsistent drug tests in a row. There is clearly something wrong requiring additional intervention between the healthcare provider and the injured worker. If a case manager is not yet assigned to the claim, this is a good time to do so. Field case management could be an effective approach, offering a face-to-face discussion with both the healthcare provider and the injured worker. Other resources could include utilization review of the prescribed medications, particularly if the prescribed medication was not detected in both test results. A treatment plan may include a prescription of different medications with appropriate therapeutic benefits, or referral to addiction specialists if appropriate.
- The claimant refuses a follow-up test after an inconsistent result, or fails to attend scheduled office visits. Adjusters may want to require prior authorization for controlled medications dispensed until the injured worker is tested for compliance. Some state guidelines require drug testing to receive further prescriptions – as is the case in New York – and offer additional regulatory support to the request. Finally, consider a field case management task assignment to review both the injured worker’s treatment plan and compliance between the injured worker and their healthcare provider.
Require prior authorization for future medications
This is an effective option when claimants refuse to undergo drug testing.
A payer will have a specific formulary of drugs allowed under their plan. Any attempted fills for medication outside of that formulary would have to pass through a prior authorization process. Formularies can also be managed at the claimant level allowing the adjuster to require prior authorization for all or specific medications prescribed to the claimant. Medications prescribed by a specific provider can also be arranged to require prior authorization. An adjuster could use the prior authorization process and require drug testing and demonstrated compliance before authorizing further fills.
Consider a pharmacogenetic test and blood dose correlation testing for chronic prescriptions
Certain individuals metabolize medications faster or slower than others. If a claimant has yielded multiple inconsistent results but insists he or she is taking medications as prescribed, and the treating provider has confirmed usage and pill counts, a pharmacogenetic test will provide greater insight into how the injured worker is metabolizing their medications.
Blood dose correlation testing results can help healthcare providers identify if patients drug concentrations are at steady state based upon the dose prescribed and identify potential metabolic issues. Blood toxicology testing is an effective indicator in determining if pharmacogenetic testing is medically necessary.
A blood medication level that falls below the expected range can be a sign of rapid metabolism. Conversely, blood medication levels above the expected range can indicate slow metabolism. In either case, this information can assist in determining the effectiveness, or possible dangers, of a patient’s current medication regimen. This can be critical information for both the healthcare provider and the payer.
Drug testing is an important tool in understanding an injured worker’s compliance with their medication treatment plan, but is only a starting point. An understanding of the available resources that will drive the injured worker’s compliance can be a crucial next step after initial assessment of test results. Understanding all available options is an essential step toward achieving patient compliance.
About Michele Settel
Vice president of the workers’ compensation division for Cordant Health Solutions™, Michele Miller Settel has over 23 years of experience in the workers’ compensation industry. Before joining Cordant Health Solutions™ in September 2013, Michele was responsible for developing operational best practice standards, training, sales, new account implementation, product development, business process reengineering and pharmacy operations for TechHealth/One Call Care Management, where she served as executive vice president of business development. She has extensive experience developing ancillary programs including pharmacy benefit programs for all payers. This broad experience was the foundation for the Cordant managed drug testing program’s incorporation of cost containment strategies with a focus on quality service delivery.
Michele has broad executive experience in managed care strategies including telephonic and field case management, utilization review and peer review services. She served as vice president of sales support for Coventry Workers’ Compensation Services for more than 17 years. She was responsible for developing enhanced product offerings and overseeing new account implementations.
Michele holds a BS in Business Administration from Missouri Baptist University, where she graduated cum laude.
About Cordant Health Solutions
Cordant Health Solutions™ offers a consolidated approach to serving the medication monitoring needs of healthcare providers and payers, offering a flexible solution and bridging scientific gaps. We offer a variety of testing options and technology platforms, plus experienced representatives to deliver a high level of service to you and your clients.
Cordant’s unique testing protocols and consolidated data systems are a roadmap through a complicated world. In a landscape full of questions about prescribing, paying for opioid therapy and the evolving laws on drug testing, we provide clear insights and straightforward answers.