Healthcare is complex, and in workers’ compensation, it continues to grow more complex day by day. Prescription drugs alone – due to a multitude of factors such as controlled substances, treatment nonadherence, comorbidity and specialty drug trends – continue to be the largest contributor to escalating cost and duration on longtail claims. Add to this the complexity surrounding ancillary medical products and services, and the know-how required by claims staff to navigate these varied services and vendors.

But that doesn’t mean workers’ comp stakeholders have to experience it in a complex way.

The value provided by a truly exceptional medical cost containment program is more than the sum of its individual products and services. Instead, consider this: how do its components come together in the most intuitive and effective way to enable optimal financial, clinical and claims operational outcomes?

Creating and delivering the most optimal solutions to address this question is what drives us every day. We deliver all the components you might expect from a pharmacy and ancillary benefits manager, and more. But more importantly we manage the workers’ comp claims experience. Beginning with you, the customer, and your claims staff – and carrying this commitment all the way through to the patient.

Insurance carriers, employers, TPAs and state funds rely on Healthesystems to deliver value in these critical areas:


Greater overall containment of pharmacy and ancillary costs compared with their previous medical cost containment partner

An exceptional claims experience for the end user that translates into more efficient processes and management of the injured worker

An adaptive program that enables payers to deploy their own market-differentiating strategies

A data-rich environment that informs and drives optimal management at the population and patient levels

Enforcement of clinical best practices through advanced technological applications and concierge-style clinical consultative and intervention services

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Often, a prescription drug is the payer’s first point of visibility into a newly injured worker’s medical activity. It also represents an early and significant opportunity to impact the trajectory of that claim and a positive patient experience. But due to the complexities of treating pain and injury, medications also have the potential to eventually drive hundreds of thousands of dollars in unnecessary medical and lost time costs, and sentence a patient to reduced function and quality of life for the long-term.

We all have a role in avoiding any missteps that can mean the difference between a positive outcome – or a claim becoming part of the 10% that drive the lion’s share of pharmacy spend. Our role is to provide a structure that gives our customers better and more insightful control over the prescription activity occurring within a claim, from the moment an injured worker steps into the pharmacy to fill their first prescription.

Our PBM program structure enables the management of injured workers throughout the entire continuum of care through:

PBM Program Features

  • National retail pharmacy network
  • Extended pharmacy network capabilities and options
  • Fully integrated retrospective bill processing & conversion program
  • Electronic connectivity with major third-party billers
  • Automated prior authorization workflows
  • Regulatory & compliance support
  • Advanced analytics & interactive reporting capability
  • Clinical Concierge program providing consultation and decision support
  • Clinical intervention services, including prescriber, provider & patient outreach
  • Opioid management program
  • Drug regimen review services
  • Client-tailored formulary & plan design
  • Step therapy protocols
  • Fraud, waste & abuse program
  • First fill program

Technology With a Purpose

We developed our technology with a very specific vision: 1) Provide the most robust technology user experience for claims professionals, 2) Provide automated workflows to maximize operational efficiencies and integrate with all necessary claims stakeholders, and most importantly 3) Positively influence patient outcomes.

Our platform provides ease-of-use for the end user in navigating prescription activity among their claims, while driving real-time information into the decision-making process.

The result? A more efficient and effective claims process that:

Optimizes claims staff performance

Reduces friction and delays at the pharmacy counter

Expedites dispensing of appropriate therapy

Improves adherence to formulary recommendations

Reduces out-of-network activity

Reduces end user frustration

The Clinical Difference

Prioritizing what is in the best interest of the patient and basing all decisions on sound, evidence-based clinical knowledge is the best way to restore injured workers to good health and quickly return them to work.

Our full-service clinical program stands apart from the industry, beginning with the depth of in-house pharmacology and occupational health experience, and the way this knowledge is embedded within the tools and workflows included in our platform and service delivery.

All customers are assigned a clinical pharmacist who provides concierge-style consultative support that includes ongoing analysis and program consultation, claims staff support, and the deployment of high-touch intervention and outreach services designed to influence prescriber and patient behaviors.

Actionable Data Analytics

The days of running reports and sifting through data to glean insight are in the past. Data should be interactive. Intuitive. Consumable. And above all, it should inform and drive action.

We continue to put forth market-leading capabilities in how we curate and socialize data with our customers to deliver program, population, and patient-level insights that:

Optimizes claims staff performance

Reduces friction and delays at the pharmacy counter

Expedites dispensing of appropriate therapy

Improves adherence to formulary recommendations

Reduces out-of-network activity

Reduces end user frustration

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The various ancillary medical services involved in the treatment of injured workers can represent over 40% of total workers’ compensation medical spend. They also tend to be the most challenging to implement and deploy within a payer’s overall cost containment program due to some significant limiting factors.

The multitude of products and vendors creates a complex environment that makes integrating, managing and/or modifying vendors difficult. It also presents an inconsistent user experience for claims professionals, who already face the daunting task of understanding the nuances between different services and each of the respective vendors. In addition to these operational roadblocks, a lack of pricing transparency continues to be one of our industry’s greatest unmet challenges. Payers have limited visibility into what comprises costs, making it difficult to objectively measure performance and outcomes, as well as ensure patients are receiving the right care at the right cost.

Flexibility, Transparency and Cost Savings

A competitive vendor network structure that provides you with best-in-class vendor choice for each respective ancillary service, while also having the flexibility to make modifications as needed without any implementation expense. Clear visibility into vendor pricing. Consistency in quality and performance. And the reassurance that the appropriateness of a product or service must be authorized before it is provided or billed.

Our ABM program is the first of its kind in that it delivers all these values to you through a single connection. As program manager, we connect you to our best-in-class vendor networks through an integrated platform that enables:

A consolidated platform for managing all ancillary services and vendor networks

Pricing and performance transparency

Maximized utilization management and cost containment capabilities

Added cost savings through fraud, waste and abuse mitigation, preferred product selection, and elimination of bill disputes

Flexibility and connectivity in network choice

Prospective management of all services

Accurate and immediate billing

Adherence to evidence-based guidelines through clinical guidance

Greater efficiencies and a consistent user experience in the claims process

See how Healthesystems end-to-end technology and services solution for managing all ancillary services and vendors delivers better claims management and quality care for injured workers at the lowest available cost.

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The fragmented workers’ comp system remains a significant roadblock to managing injured worker populations in the most holistic and effective way.

Our integrated PBM + ABM solution provides an opportunity to piece together these fragments. We give payers the most comprehensive and detailed visibility into the medical activity occurring within their injured worker populations, which helps them uncover new opportunities for clinical management and cost containment.

Clients who leverage our integrated PBM + ABM program experience:

Prospective management of 50% of total medical spend – the ability to make decisions around care before it is provided

A consolidated user interface for management of all pharmacy and ancillary activity – greater ease of use and scalability to deploy consistency throughout the claims operation

Integration of pharmacy and ancillary medical data across patient populations – including clinical and transactional information

Single platform connectivity for managing all medical services and networks – minimize cost and time for deploying changes to vendor networks and program design while removing the administrative overhead often associated with managing the billing and payment process for these services

Our integrated program is structured in a way that draws on the PBM and ABM expertise of the individual disciplines, around which is wrapped the value of our shared program services.

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