Pharmacy: Clinical Services

Workers’ Compensation Clinical Services

As workers’ compensation pharmacy regimens become more complex, you need a partner who can help you get in front of claims to protect injured workers and speed their recovery by monitoring and managing their medication regimen. You also need a partner that can help you creatively address legacy claims where months or years of dangerous polypharmacy regimens have created an evolving cascade of side effects. Preferred Medical’s experienced clinical team helps payers and their adjusters devise a plan of action to deliver the best possible clinical and financial outcomes.

Advantages of Preferred Medical’s Clinical Services include:

  • Different level of service based on the claim and Rx complexity
  • Ensure the medication regimen is not harmful to the injured worker
  • Identify and intervene earlier on high-risk, high-dollar claims
  • Creatively engage on legacy claims to facilitate settlement
  • Enhance return-to-work rates with clinically appropriate treatment
  • Engage in effective physician communication to impact change
  • Reduce opportunities for fraud, misuse and abuse
  • Meet evolving jurisdictional requirements
  • Lower claim costs

Doing The Right Thing by making evidence-based, clinically sound choices not only encourages better clinical outcomes but also better financial results. Following are the various services available that can be used by our PBM clients to implement best practices in oversight and engagement.

Individualized POS Formularies

Medical necessity & cost containment rules integrated into the pharmacy point-of-sale that includes state-mandated, Preferred’s standard, client customized, and claim specific (e.g. blocks and prior auths, step therapy, lock in/out prescribers and pharmacies, etc.) formularies.

Clinical Alerts and Triage Analysis

Our High Utilization Pattern Alert Report identifies high dosages, severe drug-to-drug interactions, controlled substance scripts from multiple prescribers or pharmacies, and other potential concerns. The triage includes retrospective analysis for hot-spot trends per claim, drug / classification, prescriber, pharmacist, etc. Coming in 1st quarter 2020: Proactive red/yellow/green clinical alerts integrated directly into our portal, My PreferredMedical.

Standard, Customized, Ad-hoc Reporting

Standard and customized reporting that can include any data element in My PreferredMedical and available on an individual’s dashboard or to run, schedule, create ad-hoc in the reporting module or made available during stewardship meetings. Our reporting capabilities gives clients transparency to understand what’s going on as it’s going on.

Educational Outreach

Proactive communication with the prescriber(s) and/or the injured worker when clinical alerts are triggered, customized for you. Better choices are made when education occurs, so articulating trends and alternatives to the two primary stakeholders that can influence choices is very important. We will work with you to identify when (triggers, timing) and how (letter content, delivery mechanism) to provide this education.

Ask an Expert

Ask a pharmacist, nurse or physician simple clinical questions through a convenient online form and follow-up correspondence via e-Mail. This is meant for relatively simple questions on Pharmacy and Ancillary services and not specific actions on claims where customer service would still be the primary contact. The scope includes the initial question and a follow-up clarification email if needed.

Clinical Advisory Services

A review conducted by a nurse to guide the claims adjuster towards a medically sound prior authorization decision. For clients that rely solely on claims adjusters to decide how to respond to prior auth requests (i.e. make a medical decision), this service can provide a clinical perspective to aid in their decision-making process.

Claim Drug Analysis

A review conducted by a nurse of the entire drug regimen to identify issues and concerns. This report is helpful for clients that want to know the details of the drug regimen (e.g. dose/symptomatology, escalation trends, drug-to-drug interactions) and concerns it may raise for communication with the prescriber and/or injured worker. The review will focus on the last one year of drug transactions processed by Preferred.

Medication File Review

An evaluation of an injured worker’s entire drug regimen by a physician utilizing evidence-based medicine and specific training on pharmacotherapy and a bio-psycho-social approach to treatment. This goes beyond a peer review to a very refined process and expert physician that will take into account whole-person treatment options and tactics going forward. Since this is only a file review it can be used for med/legal purposes to devise a strategy for dealing with non-responsive prescribers since it is outside the regulatory framework. Inputs include the last one year of drug transactions processed by Preferred, claims history and work-related medical treatment history.

Medication Peer Outreach 

A Medication File Review that also includes a scheduled call with the prescriber(s) to not only hear their perspective on past, present and future care but also to discuss possible medication or bio-psycho-social alternatives and tapering strategies (if applicable). Since a dialogue with the prescriber(s) is critical for success, Preferred will coordinate with the client for potential due date extensions. There may be additional charges for more than two prescribers, state or specialty matching, written agreement and requests for payment from prescriber(s) to schedule a conversation.

Clinical Liaison

A nurse case manager, via phone or in-person, enhances the medical literacy of an injured worker and encourages needed change by the treatment provider(s) by communication of best practices. TCM (telephonic case management) and FCM (field case management) can be incredibly helpful in holding prescribers accountable for change. But often overlooked is the value that nurses can provide to educate injured workers on their current care, what all of the medical jargon means, and alternative options (i.e. medical literacy). If a prescriber is being non-responsive, this is an alternative strategy for change by helping the injured worker better understand their alternatives and then demand more options for themselves. This is currently only available in California through our partner Rehab West.

Legacy Claims Advisory Council

A unique service (only available through Preferred) where a senior level nurse moderates a conference call between an interdisciplinary panel of physicians (PM&R, orthopaedic surgeon and behavioral psychologist) and the claims adjuster, clinical liaison and/or defense attorney. Their focus will be to discuss what options have been tried, and others that may be available, to find better clinical and financial outcomes for the most complex “legacy” claims where many tactics have already been used but none have helped settle the claim. This conversation can be recorded (so there is a deliverable) or not (which means it is not discoverable, keeping legal options open).

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