How a pharmacy benefit management (PBM) plan can ensure injured workers get the right drugs at a fair price Featured

8:00pm EDT September 25, 2010

When an employee gets injured on the job, managing the prescription drugs related to the medial treatment of a workers’ compensation claim can be a complicated task for insurance payers. That’s where a pharmacy benefit management company (PBM) can help coordinate the prescription medication benefit between the insurance payer, the injured worker and the pharmacy in the most efficient manner, says Daryl Corr, president of Healthesystems.

Over the last 10 years some PBMs have identified new ways to bring this type of service delivery to the next level

“As a pharmacy benefit management company, Healthesystems has focused our attention on using the latest technology to process real time workers’ compensation prescription transactions directly with the pharmacy,” says Corr. “This real-time processing is a benefit to the payer, the patient and the pharmacy. The electronic adjudication process applies the appropriate pricing and clinical edits to make sure the right drug is being used for the right treatment and the pharmacy is notified within seconds.”

Smart Business spoke with Corr about how a PBM can help payers maintain greater control over inappropriate treatments, in light of current trends occurring in workers’ compensation pharmacy management.

What role does a PBM play when managing workers’ compensation pharmacy costs?

Pharmacy cost is one of the largest portions of medical spend associated with treating injured workers and the complexities involved in managing these claims is challenging for many payers. A PBM such as Healthesystems provides customers with a comprehensive program to reduce the total cost of prescription care and eliminates the manual claims administrative tasks such as paper billing and payment processes. Electronic information is provided to the pharmacy in real time, before the prescription drug is dispensed to the patient.

How are workers’ compensation benefits different than a group health benefits plan?

With group health benefits, enrolled participants usually rely on a benefit ID card containing pharmacy information such as co-pay amounts that are presented to the pharmacy at the point of sale. Usually in workers’ compensation, claimants do not receive an ID card for workers’ comp benefits until after an injury occurs. Workers’ compensation benefits are normally provided with no out-of-pocket expense by the claimant, unlike a group health plan where members must enroll and are responsible for medical and pharmacy co-pays. In addition, workers’ comp patients choose their pharmacy, unlike a group health benefit in which members can select from a predetermined network.

The challenge is to ensure the pharmacy has the appropriate information in order to provide an authorized prescription.

How does technology factor into service delivery?

Technology has allowed the claims process to become nearly paperless and can provide real-time transactions. Instead of having to wait hours or even days for paper transactions to be approved, the pharmacy claims process is now virtually instantaneous.

Employing the latest technology, PBM companies like Healthesystems are able to more efficiently manage a vast network of pharmacies (in the case of Healthesystems, over 62,000 participating retail pharmacies). There is also the capability to more efficiently manage all of the workers’ compensation-specific rules and regulations, which can vary from state to state. And because there is no standardization across states, meeting the various state requirements is a challenge; a PBM is a benefit to the insurance payer by staying up to date on the constantly changing rules and regulations.

In addition, incorporating proactive clinical services delivered by a highly trained staff of clinical pharmacists helps to ensure optimal outcomes are achieved for the injured worker, as well as reduce instances of fraud and abuse.

What are some of the latest trends affecting workers’ compensation?

One of the fastest growing challenges in managing drug costs has been the recent trend of repackaged drugs being dispensed directly from a doctor’s office. This process can result in inaccurate and overpriced medications. Repackaging occurs when a pharmaceutical product is removed from its original container and put into a new container with different quantities, a new repackaging company label, and a new price for the medication. These repackaged drugs are then dispensed directly from a doctor’s office, often at a much higher cost than at a retail pharmacy.

An effective PBM program is able to quickly and aggressively address troublesome and costly trends. Incorporating the right technology can help to identify repackaged medications and assure they are priced back to the original ingredients so an insurance payer is not over-billed. PBMs such as Healthesystems also curb fraud and abuse through an evidence-based, proactive clinical review process which provides feedback directly to prescribing physicians.

The right PBM can also help prevent workers’ compensation patients from doctor shopping, an all too common practice in which patients try to obtain prescriptions such as narcotics from several different physicians. Because all transactions are being electronically tracked, a PBM can inform its customers instantly when this type of activity occurs.

As long as we’re looking out for the patient first, really truly trying to get the right drug for the treatment to get the injured worker back to work, we’re doing our job.

Daryl Corr is president of Healthesystems. Contact Healthesystems at (800) 921-1880 or info@healthesystems.com. For more information about Healthesystems, visit www.healthesystems.com.