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 [email protected]. For more information about Healthesystems, visit www.healthesystems.com.
