Medical Cost Containment Strategies for Workers’ Compensation Claim Settlement

Workers’ Compensation Payers have only one real choice in cost containment strategies that maximize outcomes for injured workers…

ANS Medical Cost Containment Programs are the only true face to face, and end to end pharmaceutical cost containment programs in the industry that genuinely put the patient first, while minimizing the cost of settlement in large loss workers’ comp claims.

 

Pharma-Medical-Cost-Containment-Graph

Have you ever wondered whether other so-called medical cost containment programs have really delivered a maximum lifetime savings result? Or do they just grab the low hanging fruit and declare victory in a largely superficial review process?
The good news is that to compare and contrast the effectiveness of medical cost containment programs, you need only to employ some common sense, and your own experience around the processes that are used by many in our industry to deliver their results.

Their Process Our Process
A Doctor makes a phone call from across the country to the prescribing physician questioning the efficacy of their pharmacy regime. (Peer to Peer) A Legal Nurse expert with intimate case familiarity visits the doctor in person at their office and face to face negotiates an evidence supported pharmacy regime in a collaborative, non-threatening way with the patient at the center of the discussion.
Repeated phone calls to physicians hounding them to agree to cost reduced protocols. Physicians actually avoid these calls or staff them out so actual peer to peer contact is rare in these cases A initial face to face visit obtains a written agreement with doctors signature for detailed drug utilization changes, and establishes a personal relationship with the doctor as a basis for productive future discussions.
Follow up is all but non-existent. A Legal Nurse expert contacts the doctor quarterly for up to a year insuring that compliance to plan is maintained and that medical changes are evaluated.
Process ends with initial set of changes to medical regime. Process never ends until settlement. Can include patient, doctor and attorney meetings as needed to produce a maximum result and expedite case settlement.
Process drags on and settlement dates keep getting pushed out due to unavailability of prescribing physicians or lack of interest in being remotely micromanaged. ANS assigns a dedicated CLO (Clinical Liason Officer) whose sole function is to provide accountability and follow up to insure compliance to the new treatment plan
MSA reductions are insufficient to achieve criteria for settlement. Because ANS does the hard work to achieve the full measure of cost reduction and maximally improved outcomes, payers can rest assured that no better option for MSA reduction exists beyond our analysis and implementation.

Pharmaceutical Cost Containment Strategies

According to the NCCI, the preeminent use of powerful, addictive drugs in the treatment of workers’ compensation claims drives over 21% of the industry’s prescription drug costs. No surprise when you consider the growing trend toward increased narcotics usage for chronic pain, the complexity of managing multiple medications coordinated between multiple prescribers, the low usage of generic brands and the difficulty coordinating between multiple healthcare providers and agencies.

ANS Cost Containment Programs work uniquely to address these and other legal issues that ensure the most rapid and cost reduced settlement of claims in the industry. Our team conducts a detailed medical history review to begin the process. We bring both core competencies and specialized credentials including MD, PharmD, and RNs certified in CCM, CRRN, CDMS, Life Care Planning, MSCC and Certified Legal Nurse Consultants. Unique to ANS’ cost containment process is that our Legal Nurse consulting team maintains a local presence in all 50 states, giving them unique jurisdictional knowledge: an important factor in navigating the medical-legal dialog in a WC settlement discussion. Some of the tactics employed include:

  • Evidence based reviews of medical necessity for prescription drugs
  • Consolidation and coordination of drug therapies between multiple prescribers.
  • Consideration of alternate medication regimes
  • Identification of prolonged duration of therapies
  • Use of generics where applicable
  • Identification of duplicate therapies.
  • Specification of weaning programs for over-prescribed narcotics
  • Identification of excessive dosages.

Cases referred to ANS for our Pharmacotherapy review show an average cost reduction of over 25% using this process. Other results include:

  1. Loss ratio reductions from 1% to 2%
  2. A Success Ratio of 94% of all case referrals*
  3. An average return on investment of 20 to 1

Peer to Peer Drug Utilization Review Sounds Great But Doesn’t Work…

While the industry is ripe with talk of peer to peer drug utilization review and how successful it can be when a doctor speaks to another doctor about changes to their pharmacy program, the reality is somewhat different. Again, one only has to apply common sense to understand how most cost containment programs with this as their fundamental operational method, are inherently flawed.

Consider the following:

  1. Doctors are very busy people, getting in to see them is hard enough. Getting them on the phone after a long day to have their patients’ drug therapies critiqued by a “peer”is near impossible.
  2. Doctors don’t particularly like having their judgment about prescriptions challenged by another doctor who they don’t know at all and who doesn’t know their patient. This reaction doesn’t occur when meeting with a Nurse expert whose relationship to the doctor in the medical hierarchy is inherently non-threatening. And yet her physical presence at the doctors office, expert case knowledge, and data based support for recommendations are universally compelling.
  3. So called “written agreements” in the peer to peer model are really faxes that are usually sent but rarely signed and returned by the claimant’s doctor. In our process, our Nurse expert does not leave without a signed, reviewed document which becomes the basis for compliance follow up.
  4. Follow up in the peer to peer model is mostly non-existent. ANS has an entire team dedicated to compliance follow up for the life of the claim.

ANS Medical Cost Containment Strategies

In addition to drug utilization review via Pharmacotherapy Review ANS provides a suite of complementary services that allow payers to align other elements of care of the injured worker with the improved outcomes that Pharmacotherapy provides.

These services include:

  1. Legal Nurse Consulting
  2. Medical Cost Projection
  3. Reducing Medicare Set Aside & Part D Exposure

To speak to a representative about any of these programs, call us today!

*At ANS, our definition of success sets us apart. We don’t count talking to the doctor’s office as a success, meeting with the doctor, contacting the doctor, etc.  The only success is when the doctor makes a change.