Red Flags in Opioid Therapy
Analyzing each claim from multiple perspectives can reveal risky situations if data are readily available and you know what to look for. and Environmental Medicine and the Official Disability Guidelines.
The large number of workers’ compensation claimants receiving prescriptions for opioid therapy requires payers to dig deeper into the data to uncover inappropriate behaviors – whether it is risky prescribing practices, questionable claimant behavior or activities that are indicative of fraud, drug abuse or medication misuse. Often the signs that a claim is veering off course escape notice because the details may seem insignificant and unrelated.
However, looking at a claim from multiple perspectives often reveals associations among activities that can add up to suspicious behaviors. Even claims with a relatively low drug spend may deserve a closer look.
In October the FDA announced class-wide safety labeling changes and new postmarket study requirements for all extended-release and long-acting (ER/LA) opioid analgesics intended to treat pain. This is the latest effort by the FDA to combat misuse, abuse, addiction, overdose and death from these potent drugs
There are a number of red flags that can alert claims professionals to take early action so they can prevent problems.
A close review of claims involving opioids may be in order if any of these circumstances are present.
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Most PBMs make a variety of tools available to assist payers in identifying and managing claims with potential for high risk. They may take the form of subject-specific reports, papers, calculators and the like. Healthesystems offers a risk management dashboard that provides an innovative way to view and manage high-risk claims in real time.
To the extent that claims professionals have the proper reports and tools available to identify red flags in claims involving opioid therapy, they can appropriately enlist help from other stakeholders and take early action to avert problems.
Depending on the payer, this can include:
- Escalating a claim to a claims manager, nurse case manager or medical director within their organization
- Reaching out to a clinical pharmacist at their PBM.
- Ordering an independent pharmacotherapy evaluation (IPE) — a review by a clinical pharmacist that looks at a claim from all angles and provides valuable guidance to put an escalating claim back on track.
- Scheduling a teleconsult if the benefit state is not an ex parte state and an IPE has been completed.