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CAREMC PHARMACY CLINICAL MODELING
Applying predictive analytics to pharmacy utilization can give employers and insurers a more proactive means of combating systemic risks and cost drivers associated with prescription treatments for ill and injured workers, CorVel Corp. says.
In June 2013, the Irvine, Calif.-based company developed and built a predictive risk analysis platform into its CareMC health care and workers compensation claims management system. The platform, called Pharmacy Clinical Modeling, is designed to predict potentially catastrophic patient cases by monitoring claim activity for specified risk indicators and usage thresholds, including high use of narcotic medications, multiple prescribers and particular combinations of medicines.
When indicators or usage thresholds are triggered, risk managers and claims adjusters using the program are sent task alerts containing guidance on claim review and possible treatment interventions, such as drug testing to ensure prescription adherence, pain questionnaires, physical therapy and additional case management measures.
CorVel's CareMC Pharmacy Clinical Modeling program was among the insurance and risk management products honored with Business Insurance's 2014 Innovation Awards.
The company's goal in incorporating predictive analytics was to expand the scope of employers' and insurers' pharmacy benefit claim management strategy beyond a myopic focus on the dollar value of claims or opioid use, said David Lupinsky, a Sacramento, Calif.-based vice president at CorVel and product manager for the Pharmacy Clinical Modeling platform.
“What we saw as we were looking at a lot of these patient cases in more detail was that we had so much data at the back end, there ought to be something we can do on the front end to try and intervene appropriately before a case reaches these high dollar amounts,” Mr. Lupinsky said.
By compiling pharmacy utilization and bill review data from employers, insurers, third-party administrators and providers into a single platform, Mr. Lupinsky said the Pharmacy Clinical Modeling feature provides risk managers and claims adjusters with a composite risk score for every patient case that includes prescription treatment.
The program is also designed to monitor for comorbidities that might stall a patient's recovery, including degenerative conditions, poor conditioning and overall health status.
“We had to start looking past the opioids themselves and identify the other common risk factors among these patients early enough in the claim that we can get out in front of them before it becomes a problem,” Mr. Lupinsky said. “It helps to identify what we call the creeping catastrophic claim, where you have a claim that starts off with low severity but seems to get worse and worse over time.”
All of the entries for the 2014 Business Insurance Innovation Awards were reviewed by an independent panel of judges, all of whom are risk management professionals.