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.
