502.495.5040

News - 2012

Unnecessary Drugs at Very Good Prices

Apr
05

Sometimes when driving, I’ll get lost. Like most men I am reluctant to ask for directions. When my condition is pointed out by my wife (without fail) I will respond, “I may be lost but I’m making great time”. So many carriers have great deals with Pharmacy Benefit Managers (PBMs), receiving impressive discounts on their pharmaceutical purchases.
 
Unfortunately, these discounts are for drugs they shouldn’t be buying in the  first place.  Post-award medicals are the great black hole of workers’ compensation medical expense; pharmaceuticals are the fastest growing component of this abyss. Often, this is because drugs are on autopay and/or the carrier is depending upon its PBM to monitor these charges. Remember, the PBM makes no money unless it sells drugs. Granted the price schedule for what you buy may be attractive but, often, you shouldn’t be buying in the first place.
 
PBMs and their pharmacists will warn you about drug interactions, or attempts to refill dnigs too soon, but they don’t point out that the opioid being prescribed 3-years post surgery, while safe, should have been stopped some 2 % years earlier. They may identify appropriate generics but don’t tell you that the use of that particular drug could not be reasonably related to this specific work-related injury. Or that taking multiple drugs, though safe, may indicate a condition for which the carrier would not be responsible (e. g. diabetic neuropothy, depression, etc.), PharmCLEAR® physician advisors are experts at pharmacy.
 
Let us audit your PBM statement and make sure you’re paying for only those drugs that are scientifically related to the injury for which you are responsible.
 
PharmCLEAR®.
 
We can do better.
William V. Faris, JD

Squeezing TPA’s for Profit and other Myths…

Apr
02

Squeezing TPAs for Profit and other Myths….Or it seems the more I cut my administration/claims medical management, the faster my over all claims costs go up!!!  I can’t begin to list the number of self-funded clients I have advised over the years that want to focus on squeezing the absolute last nickel from the 15%-20% administration budget.  All of this effort on the “overhead” component of the claims dollar while paying only lip service to ever escalating medical/pharmaceutical costs.

And what do you get when you take a sledgehammer to the administrative budget?  

  1. Adjusters/case managers with too many files,
  2. Rubber stamp UR
  3. Less effective provider networks
  4. Runaway drug costs

My advice is to pick the right vendors but pay them a fair fee to properly handle the claims and not just be a check processor.  Then, spend your energy and invest your loss control dollars on effective medical management of your claims.  These include:

  1. Aggressive/early intervention with nurse case managers
  2. Enhancing the UR function to improve patient accountability and optimize outcomes,
  3. Address extent and duration of prescription usage, not just cost of pills purchased,
  4. Secure the right specialty match physicians for peer to peer remediation with treating physicians.
  5. Constantly monitoring your  physician networks to ensure your providers have the best skill sets, not just the lowest price.

At OMCA, we work with TPA’s, adjusters and self-funded employers to make sure medical costs are contained.  

Call us, we can do better

William V. Faris, CEO, President
502-495-5040

Doctor shopping – We search & uncover chronic abusers

Mar
28

Just another day. That’s what I thought as I read the Courier Journal and saw two articles about prescription drug abuse.  The first article detailed a Kentucky physician’s license suspension. This Louisville physician pre-signed prescription pads authorizing narcotics for his patients. He instructed his nurse practitioner to use them and also made them available to the office manager, receptionist and other staff members.
The alert nurse practitioner accessed the KASPER data base and determined that 81 of the 91 patients seen that day were doctor shopping, having already received narcotics from other physicians in recent days. Imagine that! 89% of the patients FOR THAT DAY were doctor shopping — and were accommodated! The second article noted a former Humana employee had been sentenced to a year and a day in prison for stealing the identities of four patients and using that information to get prescription painkillers for himself. His attorney said his client had become dependent upon hydrocodone after having been prescribed it following surgery on his leg.
What’s the chance the ex·Humana employee or one of the 81 patients receiving bogus prescriptions were workers’ comp claimants? Pretty likely, I’ll bet. As always, comp is not the only factor in prescription drug abuse but it continues to be a major one. As prescription drugs drive soaring medical costs in all comp systems, are you doing all you can to contain them? Cunning claimants and facilitating physicians can cost you dearly. We have the clinical resources to “search and destroy” chronic abusers.
Call us. We can do better.

Snitch or Hero?

Mar
21

Telling the Medical Licensure Board—Snitch or Hero?

We all know about the problems caused by the few bad doctors who over prescribe dangerous narcotics.  This is especially true in certain parts of Kentucky where it devastates families and communities.

Board Certified Peer Reviewers can be instrumental in controlling costs when they personally contact treating physicians to discuss alternate treatments, to point out the latest published medical evidence and to collaborate with providers to make sure injured workers are receiving the best possible care.

However, effective peer review physician panels become heroes when they pick up the phone and report obvious/dangerous narcotic abuse situations to medical licensure boards or other regulators.  The best reviewers to sit on the sidelines when those few rogue operators are operating outside the law and without regard for an injured worker’s long term health.

Utilization Review means never having to say UR sorry

Mar
16

Dangerous Hospitalizations and Alarm Fatigue

Being in the hospital is a dangerous thing. ECRI Institute is an independent, nonprofit organization that researches the best approaches to improving the safety, quality, and cost-effectiveness of patient care. In a recent publication they listed the top ten technology dangers patients face when hospitalized. Three apply directly to hazards faced by all patients, whether work comp or group medical.

First is alarm fatigue! Who knew? Apparently so many pieces of equipment have alarms on them that staff begins to become numb to the sounds of alarms. Next is excessive exposure to radiation from CT scans and radiation therapy. Not the norm but when mistakes are made as to dosage, the results can be critical. And then there are medical errors when using infusion pumps. Doctors, nurses, pharmacists and others contribute to this with illegible orders, improper delivery and mixing up patients.

Unnecessary hospitalizations can be expensive and deadly. Good utilization review can make sure that only those who need the intense services of in-patient care are exposed to this environment. This saves both money and lives.

OMCA is accredited by URAC for both health and workers’ compensation utilization management. Call us. We can do better. 502-495-5040

William V. Faris, JD
President and CEO

Next Page »« Previous Page