How to Avoid Extra Expenses in Workers' Compensation

Dec 3, 2014
When prescriptions are processed through third-party billers, the PBM’s point-of-sale safety net is removed. Payers lose the value of their formulary, and prescriptions forego drug utilization review.
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  • Workers' Compensation Insurance

Imagine you’re in the process of renting a car for vacation and the agent asks if you want to buy additional insurance coverage from the rental car company.

Do you need it? Your personal auto policy coverage is extended to any borrowed vehicle, including rental cars, and includes your liability and collision repair coverage.

Essentially, you would be paying an expensive amount while gaining no additional value.

In workers’ compensation, third-party billing costs payers money and actually lessens value for payers and their injured workers.

The Cost of Third-Party Billing

When injured workers do not present their prescription ID cards when obtaining medication at a pharmacy, the pharmacy may process the script through a third-party biller rather than through the pharmacy benefit manager’s efficient and safe electronic billing process used for in-network prescriptions.

Unfortunately, the use of a third-party biller drives up the cost of the prescription. It is estimated that third-party bills cost payers $40 million in pharmacy-related waste.

Additionally, when prescriptions are processed through third-party billers, the PBM’s point-of-sale safety net is removed. Payers lose the value of their formulary, and prescriptions forego drug utilization review (DUR). This not only contributes to missed cost savings for the payer, but poses increased risks for the injured worker including adverse drug interactions, narcotic overdosing and other potential drug-related problems.

Avoiding Downstream Costs

Analyzing our nationally representative database of workers’ compensation claims, approximately 39% of prescriptions processed through third-party billers in 2013 were for a narcotic medication.

With narcotics’ high potential for dependency or abuse, proactive management programs such as Morphine Equivalent Dose (MED) help manage utilization. However, these types of solutions are only applicable when prescriptions are processed directly through Express Scripts, bypassing a third-party biller.

Missed reviews like these not only add additional costs and safety concerns for the initial prescription fill, but increase potential for negative cumulative impact for all future fills.

Clinically Sound, Cost-Saving Solution

Express Scripts’ comprehensive visibility into the injured workers’ prescription data ensures safe treatment outcomes.

Our innovative approach to managing out-of-network pharmacy bills through paper bill conversion helps payers maximize savings and increase the use of their network. It also applies clinical reviews of the prescription to ensure appropriate and injury-specific therapy utilization.

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