BI’s Article search uses Boolean search capabilities. If you are not familiar with these principles, here are some quick tips.

To search specifically for more than one word, put the search term in quotation marks. For example, “workers compensation”. This will limit your search to that combination of words.

To search for a combination of terms, use quotations and the & symbol. For example, “hurricane” & “loss”.

Login Register Subscribe

2012 Innovation Awards: Qualified Medical Intervention

2012 Innovation Awards: Qualified Medical Intervention


Qualified Medical Intervention

Qualified Medical Intervention is a product developed by PRIUM to help risk managers and workers compensation managers mitigate the risk of injured workers becoming addicted to narcotic medications.

Overprescribing addictive narcotics to injured workers is a significant concern among employers, insurers and other claims payers looking to control pharmaceutical costs while the nation's widespread use of opioid pain medications reaches epidemic levels.

In response, PRIUM created its QMI suite.

Duluth, Ga.-based PRIUM is a medical cost management company and a 2012 Business Insurance Innovation Award winner for its QMI product, which relies on peer-to-peer discussions with prescribing physicians.

It also relies on nurses who follow up and ensure that the treating doctors comply with modified treatment plans agreed to during the physician-to-physician discussions.

But PRIUM's approach is different from typical utilization management and peer-to-peer practices, said Michael Gavin, the company's chief marketing officer.

First, PRIUM prioritizes its doctors' discussions with treating physicians by going beyond the usual number of phone calls it will make to reach the claimants' doctors to engage them in discussions focusing on evidence-based medical practices, Mr. Gavin said.

“We will make 10, 20, 30 phone calls to the physician's office until we can get someone on the phone who will talk to us about the case, preferably the prescriber,” Mr. Gavin said. “That has led to a discussion rate of about 89% of cases over last year.”

About 70% of those discussions result in the prescribing doctors agreeing with the recommendations made by PRIUM's review doctors to modify the claimant's medication regimen, according to PRIUM.

PRIUM trains its doctors to engage only in “collegial discussions” when presenting their case for applying evidence-based disability and medical guidelines, Mr. Gavin said.

“What we are tying to do is impact treatment for the patient, so we are looking for doctors (who will not) look down their nose at the treating physician,” Mr. Gavin said.

Then PRIUM's nurses contact the doctor's office before and after an injured worker's office visit. The oversight nurses are assertive to assure treating doctors follow the agreed treatment plan, Mr. Gavin added.

In their oversight role, the nurses also monitor daily prescription fill records for red flags. Claims adjusters and treating physicians are contacted quickly if the nurses find a written prescription that was not agreed on.

The entire process begins, however, with PRIUM identifying claims that need further investigation based on triggers that often are discovered by analyzing a payer's claim system or data from their pharmacy benefit manager's system.

PRIUM says its QMI process has resulted in $6 in savings for every $1 payers invest. But it's not just about helping employers—QMI also helps save workers from the devastating problem of addiction, Mr. Gavin said.

Read Next