What's Right in Workers' Comp

Medical management strategies often focus on avoiding what can go wrong. But we believe there’s a bigger opportunity to help things go right.

Our strategies are designed to comprehensively support workers’ compensation professionals and the patients they service – arming them with the solutions they need to impact care and improve claim outcomes.

Our Solutions & Services

Improving Patient Care

Even the most motivated injured worker’s recovery can be hindered by obstacles and unexpected developments.

Healthesystems’ robust pharmacy and ancillary programs provide the opportunity to comprehensively manage a patient’s care from the time of injury and throughout the lifecycle of the claim. We understand that delivering the right care at the right time can have a profound impact on the clinical and cost outcomes of a claim – and that these care needs change over the course of an injury. Our goal is not to stand in the way of care, but rather to guide a claim along its most successful path, deploying strategic interventions to keep it on course.

Partnering with Payers

Our clients understand that traditional solutions will not produce exceptional results in an evolving healthcare landscape.

Our programs go beyond traditional medical cost management strategies to meet the unique needs of our customers and their patient populations, identifying new trends and opportunities to stay ahead of industry challenges. We offer customizable, scalable solutions that maximize cost savings opportunities and achieve more effective, more efficient, and more affordable outcomes for our customers and the patients we collectively serve.

Supporting Claims Professionals

Claims professionals are on the front line, where quick thinking and decisive action are critical.

When the course is unclear, the right tools can guide claims back on track. Healthesystems is there to provide our users with the information they need to make informed, time-sensitive decisions about patient care.

  • With real-time alerts, easy-to-access claims information and embedded clinical guidance, our Verticē claims portal helps claims professionals make important decisions at critical points in care
  • Our clinicians are just a phone call or email away for medication-related questions at our Ask a Pharmacist drug information line
  • Our 24/7/365 Customer Service Center answers 98% of calls in 30 seconds with a real person

Connecting with Pharmacists

Communication is essential to patient safety, and pharmacists require up-to-date information to feel confident they are dispensing appropriate medications.

Healthesystems exchanges pharmacy information in real-time to manage transactions prospectively at the point of sale, preventing the wrong medications from making it into the hands of patients, and our 24/7/365 Customer Service Center offers proactive assistance whenever pharmacists face difficulty processing a transaction.

Fostering Service Excellence

In the delivery of ancillary products and services, payers require transparency to ensure that patients are receiving appropriate care quickly and effectively, and at an appropriate price.

Healthesystems chooses vendor partners who are aligned with our goal to deliver quality and cost effective ancillary medical products and services. Vendors can only enter the Healthesystems network after displaying in-depth clinical expertise, significant network coverage, and strong data capture abilities, all of which we use to regularly evaluate performance metrics to add value and flexibility in our clients’ choice of ancillary providers.

Engaging with Physicians

Clinical expertise is the bedrock of care, and injured workers are a unique patient population with specialized needs and considerations.

But with workers’ compensation patients representing a small portion of the healthcare population, many physicians are not well-versed in treatment guidelines for conditions common within this unique population.

Our physician outreach programs are developed by our clinical staff, who are experts in occupational medicine and pharmacotherapy as it relates to the treatment of injury. Targeted communications alert prescribers when there is an opportunity to modify prescribing behaviors that contribute to suboptimal claims outcomes and excessive costs.

Our goal is to support physicians with the information they need to make prescribing decisions that align with evidence-based recommendations for the workers’ compensation population.

Our Solutions and Services

Pharmacy Benefit Management (PBM)

Our PBM solution for workers’ compensation sets new standards for value and performance. We go beyond processing prescription drug transactions to more comprehensively manage drug utilization and spending. By integrating clinical expertise and advanced technological capabilities, we eliminate cost drivers while ensuring that injured workers receive quality care.

Aggressive medication management

  • Highly customizable drug formularies that address unique patient and customer needs
  • A comprehensive Opioid Management Program that fully manages opioid usage among claims populations
  • Physician outreach and other strategies for reducing prescribing practices such as physician dispensing, compound medications, and polypharmacy
  • Clinical consultation for the management of high-cost specialty drug therapies and other medication outliers

Claims process efficiency

  • Replacement of manual tasks with automated workflows that reflect client requirements and evidence-based medical guidelines
  • Robust web-based tools that provide clinical decision support to claims professionals
  • Real-time pharmacy data exchange to ensure the efficient delivery of appropriate medications


Our Solutions and Services

Ancillary Benefits Management (ABM)

Our ABM program offers a centralized platform for managing the quality and costs of ancillary products and services including Durable Medical Equipment (DME), Home Health, Transportation and Translation, Physical Medicine, and Diagnostics. Our proprietary ABM solution prospectively adjudicates all ancillary services prior to being provided, resulting in greater savings and optimal utilization.

Our ABM program offers:

  • A centralized platform that automates traditionally manual tasks to unburden claims professionals
  • Built-in strategies to mitigate fraud, waste and abuse, including greater billing transparency on ancillary products and services
  • A competitive vendor network that allows us to provide our customers with data on service performance, spending, and clinical outcomes
  • The expertise of our clinical staff to ensure products and services are managed in accordance with evidence-based medicine


Our Solutions and Services

Clinical Services

A diverse group of clinicians with backgrounds in occupational medicine and pharmacotherapy help drive extraordinary results. Individually, they bring specialized knowledge of musculoskeletal injuries, pain management, alternative therapies, specialty drugs, managed care and other areas critical to workers’ compensation. We integrate their expertise into our best-in-class pharmacy and ancillary medical solutions. The clinical staff plays a significant role in shaping our cost management solutions by:

Our Clinical program includes:

  • Providing evidence-based clinical guidance for drug plan design and automated workflows
  • Identifying specific risks and opportunities within claimant populations, as well as individual patients or prescribers
  • Offering continuous program performance reviews with quality improvement initiatives
  • Conducting special services such as educational prescriber outreach, consultations on medication and alternative therapies, and independent pharmacotherapy evaluations (IPEs)


Workers' Comprehensive

News and Views in Workers' Comp

Stay up-to-date on trends impacting your business with our monthly e-newsletter.

Get news delivered to your inbox.

Privacy & Terms of Use    |    Contact    |    Careers

©2018 Healthesystems