A Healthesystems publication

Spring 2015

Reading Between the Lines of a workers' comp claim

In complex claims involving multiple stakeholders, a pharmacy benefits manager is uniquely positioned to apply a big-picture perspective to management of the injured worker and reveal underlying risks that may jeopardize outcomes. 

Management of the injured worker is often complicated by the nature of pain and its treatment. An injured worker claim may involve multiple prescribers, complex treatment regimens, and the presence of comorbid or psychosocial factors that can negatively impact recovery. From the limited view of a single stakeholder, the full impact of these concerns can be difficult to ascertain. Prescribers can make the best possible treatment decisions with the information at hand; but if a key piece of information is missing, recovery can take a wrong turn. 

Without complete data treatment concerns go unnoticed

This injured worker case study is an example of how a seemingly straightforward claim can quickly become complicated in the absence of stakeholder communication. The specialist treating the injury prescribed an opioid analgesic to manage Doug’s acute pain and an NSAID to reduce inflammation. She has also prescribed carisoprodol for muscle spasms. She is unaware of Doug’s history of hypertension, or that his general practitioner has prescribed Vicodin® (hydrocodone/acetaminophen). The general practitioner has also dispensed a trial of alprazolam and fluoxetine to “see if they help” with the symptoms of anxiety and depression that have developed post-injury. 

Neither prescriber is aware that Doug’s alcohol consumption has increased, or that he has not been taking metoprolol to treat his hypertension as directed due to the number of medications he must now keep track of. However, the prescription continues to be filled regularly through his private insurance via mail-order, so his spotty adherence goes undetected.

The pharmacist at the local retail pharmacy where Doug fills his prescriptions has noticed that Doug sometimes comes in a few days early every month for his opioid prescriptions, but is less consistent with his NSAID fills. However, in the mind of the pharmacist, it’s not enough to raise a red flag. The pharmacist is unable to see all of the medications Doug is taking, due to the fact they are being dispensed through different channels. She is also unaware of his newly developed psychosocial concerns — knowledge that provides a troubling context for his refill patterns. 

From each of the stakeholder’s perspectives, there are no major red flags that indicate a serious threat to Doug’s health or recovery. However, when stakeholder knowledge is combined, a very different — and highly concerning — story begins to emerge.


Ensuring the safe and effective treatment of an injured worker goes beyond flagging disparate pieces of information. Doug’s case must be reviewed in its full context to successfully identify the underlying treatment concerns. A pharmacy benefits manager (PBM) can help read between the lines and fill in the gaps by ensuring that all pertinent data are being considered, allowing for more informed treatment decisions. 

In this case, there are multiple prescribers and dispensers of medication. There is also some critical information that is not visible on Doug’s workers’ compensation claim, including his history of hypertension, and undocumented behaviors such as nonadherence. Through a full medical record review and analysis, the PBM is uniquely positioned to provide a 360-degree perspective, revealing a veritable list of concerns that may have been difficult for any single stakeholder to identify on their own.

Doug represents a very real scenario in workers’ compensation that can go overlooked by a cursory review of prescription transaction history. The failure to detect critical concerns in the treatment plan can unnecessarily extend the life of the claim and drive up costs, which often increase exponentially over time. Complex claims such as Doug’s benefit from a high-touch, holistic approach to management that can better identify early intervention opportunities. Reducing risk levels earlier can effectively course correct the claim, increasing the opportunity for successful outcomes such as improved functional status and return to work.


Identifying treatment concerns through medical record review and analysis is just one aspect of holistic patient management. Outcomes can only be impacted if action is taken based on the information gleaned from this initial step. Now armed with all of the necessary information, the PBM can facilitate stakeholder communication and provide effective clinical decision support that can help optimize the patient’s treatment plan to reduce risk levels and improve functional status, while also considering cost-effectiveness for the payer.

Early intervention by Healthesystems clinical staff has successfully impacted outcomes in 4 out of 5 complex claims. Successful outcomes could include a change in treatment plan based on clinically supported recommendations, such as discontinuation or tapering of a dangerous or unnecessary drug, adding a medication that was lacking from the treatment plan, decreasing or increasing dosage of a medication as needed, or considering an alternative therapy when medically appropriate. Other examples of successful intervention may not be specific to the drug therapy regimen itself, but could include consolidation of multiple prescribers or pharmacies, or patient evaluation for abuse, diversion or nonadherence.

A large part of an intervention’s ability to significantly impact outcomes relies on the prescriber and their willingness to incorporate recommendations into a treatment plan. However, the success of intervention is also influenced by a number of other factors.

Increased communication
Although positive outcomes are achieved through indirect and direct methods of communication with prescribers, a direct teleconsult results in a higher rate of success
Earlier intervention
The younger the claim, the more opportunity for impact. Interventions within the first 6 months experience the highest rates of success
Non-dispensing Physician
Greatest interventional success is observed when working with prescribers who do not office dispense


Healthesystems combines exceptional analytics capabilities with unrivaled clinical expertise to identify and eliminate the complex risks that jeopardize outcomes for payers and their injured worker claimants. To learn more about how we can help monitor and manage your claims population, visit www.healthesystems.com/reveal.



Table of Contents