In workers’ compensation, prior authorization is the process by which an adjuster or nurse case manager reviews an injured worker’s claim status when a medication has been rejected. They determine if it should be processed and whether it is appropriate for the compensable injury.
This process is an effective way to help adjusters and nurse case managers meet a two-part goal. First and most importantly: ensure safe and effective treatment for injured workers; and second: control prescription drug costs.
To do this, adjusters need an efficient, convenient way to facilitate prior authorization with easy access to clinical and comprehensive prescription data.
OASIS: More Than Prior Authorization
At Express Scripts, we can help nurse case managers and adjusters meet these objectives. This process is facilitated by OASIS, our proprietary automated technology for streamlined communication with the pharmacy and claims staff. The tool helps adjusters do their job efficiently and effectively.
Ensuring Safe Treatment of Injured Workers
A comprehensive view into injured workers’ prescription data ensures safe treatment outcomes by helping prevent drug interactions, duplication of therapy, harmful side effects and abuse or misuse. Through OASIS, adjusters can analyze the prescription history and previous authorizations when reviewing a proposed new medication.
In addition, OASIS shows the morphine equivalent dose (MED) associated with each narcotic drug. MED is the calculation used to determine a narcotic medication’s morphine-like potency in conjunction with its dosage. Calculating the MED provides insight into the total dosage of narcotics that an injured worker is being prescribed as part of his or her treatment regimen to reduce the risk of misuse or abuse.
With this information built into OASIS, adjusters can make informed decisions when evaluating a narcotic for authorization, and can even make adjustments to the preset MED limits to ensure the safest treatment for injured workers.
Containing Costs for Payers
Express Scripts is committed to helping adjusters make cost-effective decisions. For example, with each drug that requires prior authorization, OASIS provides the average wholesale price (AWP) and the drug ingredients. This helps provide insight to the cost of treatment, specifically for compounded medications, which are a major cost driver for payers.
Within OASIS, adjusters can also modify previous authorizations to extend a treatment date, adjust specific medication limitations and include or exclude multiple prescribers. Using OASIS for prior authorizations helps to ensure that the medications being prescribed are related to the injured worker’s compensable injury.
Added Convenience For Adjusters and Nurse Case Managers
A convenient and efficient prior authorization process is the means to meet adjusters’ goals. OASIS provides for ease of use at multiple levels. The tool can be customized for single sign-on capability, and is also mobile-optimized, with capability to authorize medications on-the-go.
Additionally, when claims require further information from the prescriber, the tool can generate letters of medical necessity to the prescribing physician. OASIS even provides visibility into the letters that we have sent to the prescriber or injured worker, for concerns such as compounds or narcotics.
Finally, OASIS allows managerial oversight to view authorization activities.
Working together to ensure safe treatment and cost containment, all while adding convenience for adjusters. That’s our goal with OASIS.
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