Determining what prescriptions should or should not be approved can be a challenge for adjusters. With increasing prices, prescription medications comprise a significant share of workers’ compensation costs.
According to the NCCI Research Brief, “Workers Compensation and Prescription Drugs: 2016 Update”:
Prescription medication costs increased 11% in 2014
The projected prescription drug share of total workers’ compensation medical costs for accident year 2014 was 17%
Prescription medication averages approximately 45% to 50% of annual medical costs for active claims older than ten years
If this upward trend continues, it is important for the adjuster to consider the increasing costs of prescription medication when setting medical reserves for a claim. At the same time, insurers should not lose sight of the importance of the correct and timely approval of prescription medication for workers’ compensation claims.
Prescriptions: Approve or Not Approve?
When it comes to prescription pain medication, there are different factors and circumstances to consider before approving the pain medication.
Take the example of a claim where the woman was previously addicted to prescription pain medication. She had a right knee arthroplasty performed resulting in extreme amounts of pain. Since she cannot take prescription pain medication, the doctor prescribed her Suboxone. This particular prescription medication is used to treat people with a history of prescription drug abuse and can also be used for pain relief. In most cases, an adjuster would not initially approve it, but in this case it is necessary to alleviate the patient’s pain.
Most companies use third parties to monitor prescriptions such as pharmacy networks, pharmacy benefits manager and utilization reviews. However, the adjuster is still responsible for approving the medications if a prior authorization is required, which it almost always is.
Time is also a factor with prior authorizations. Since the pharmacy cannot fill the prescription until the adjuster reviews and approves the medication, someone who had surgery two days ago may be suffering without pain medication.
Another reason why prior authorizations are required is to ensure only the medications specifically for the workers’ compensation claim are approved by the adjuster. Many times, during an office visit, doctors will prescribe pain medication for a claim along with routine medication for high blood pressure or diabetes.
There are times where prescription medications are not necessary. In one instance, a woman was prescribed the pain relief cream Pennsaid 2% Solution that cost over $3,000.00. In this case, we would not approve the prescription because of the cost and the fact that there were alternative pain relief creams available. The doctor ended up prescribing her over the counter pain relief cream that worked.
Prescription approval for workers' compensation claims can be a challenge for adjusters. Before approving or denying prescriptions, adjusters should research the uses for the drug and also the scenario of the claim as each can be different. There are multi-purpose medications that may be classified as one purpose but used for another.
This may help keep costs down and will certainly assist in setting the proper reserve for the claim.
With prior authorizations required for almost all claims, approval or denial of prescriptions need to be completed in a timely manner.
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