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Triggers can alert benefit managers of potential cases of abuse

Proper threshold assures warnings taken seriously


Third-party administrators are leveraging pharmacy and claims data to develop red flags used to alert adjusters when injured worker cases need more attention.

But as these triggers grow in number and complexity, steps need to be taken so alerts are not ignored, experts warn.

Triggers that range from inappropriate drug and medical treatment to a worker's comorbid conditions and negative mindset signal that a claim can result in high costs and warrants intervention, whether through a nurse case manager, drug utilization review or other method.

The goal of flagging high-risk cases “is to identify those as early as possible,” said Ron Skrocki, Wayne, Pennsylvania-based vice president of product management and development at managed care services provider Genex Services L.L.C. “Earlier identification is going to lead to a more effective intervention and a better and faster outcome.”

Most importantly, flagging identifies “potential safety issues,” said Carol Valentic, Sunrise, Florida-based vice president of operations and director of cost containment at Broadspire Services Inc., part of Crawford & Co. It also “makes sure that we don't pay for things that are not covered by workers compensation.”

TPAs mine claims data for information on the worker and indicators of severity and cost that are higher than normal, Mr. Skrocki said.

Genex examines the injury, the worksite, the worker's characteristics, comorbid conditions and the employer's history, he said.

For example, a worker with diabetes may signal the need for an intervention, as it will likely take longer to recover from injury than someone without diabetes. A nurse case manager may be assigned to ensure a smooth recovery period.

Some red flags, such as a negative attitude or lack of support at home, can prolong the claim but are not apparent in the data.

Workers “don't walk around with a sign saying "love my job,' "hate my job,' or "lack family support,'” Mr. Skrocki said. To understand what's beneath the surface, it's necessary to call the case manager, he said.

Pharmacy benefit managers review their data for red flags, looking for problematic prescribing patterns, dangerous drug compounds and other safety hazards, said Jennifer Kaburick, St. Louis-based senior vice president of workers comp product, compliance and strategic initiatives with pharmacy benefit manager Express Scripts Holding Co.

Such warning signs include prolonged opioid use, harmful prescription cocktails or using narcotics for reasons other than intended, she said.

These triggers arise when a worker fills a prescription, prompting PBMs to alert an adjuster to look into a case further.

But “it's also necessary to look at the data from a proactive standpoint before the meds have been dispensed,” by calculating the morphine equivalent dose — the relative potency of different narcotics to morphine — of a worker's prescriptions, Ms. Kaburick said. For example, if a worker's prescription exceeds 100 milligrams of a morphine-equivalent dose, an alert is sent telling an adjuster to review the prescription before it can be filled. Express Scripts' clients sets the morphine-equivalent dose threshold and can choose to be alerted when a worker exceeds it.

Nonformulary drugs also go through a preauthorization process in which a team reviews whether the medications are appropriate, Ms. Valentic said. Broadspire's physicians may call the prescribing doctor to better understand the treatment plan.

It's important to understand “the overall picture” of the worker's situation to avoid unnecessary flagging, such as a worker prescribed opioids after recently undergoing surgery, said Anne Levins, Philadelphia-based director of product development and information strategy at Coventry Workers' Comp Services.

With so many potential red flags, administrators are at risk of overloading adjusters with alerts.

“Too many alerts (may) end up going on deaf ears,” Ms. Levins said. So Coventry aggregates multiple alerts into one and decides on the best time to notify the adjuster, she said. It's also important to send an alert with a solution, she said.

“Just alerting without the understanding of what (the) next step is isn't going to be very beneficial,” she said.

“You've got to keep tuning and monitoring” alerts, “because just sending people notes or emails without following up” isn't effective, Mr. Skrocki said.

Regarding the case, it's important to ask, “What was the outcome? Does that mean we have to educate people? Do we have to refine the triggers? Do we have to have a better delivery mechanism or workflow for the triggers?” he said. “It's not a one-and-done kind of situation.”

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