Employers, claim payers and workers' compensation care management organizations continue to be challenged to provide solutions for rapidly escalating workers' compensation medical costs. According to a recent study released by the National Council of Compensation Insurers (NCCI), pharmaceuticals and related costs account for approximately 14 percent of workers' compensation medical costs. Pharmacy spending in workers' compensation is now one of the top cost drivers for lost-time claims. While technology and related services have been a significant component of medical cost-management strategies, many employers have adopted a more advanced model that is driving significant levels of additional medical and pharmaceutical cost savings.
Tight Integration Successful
Additional incremental value comes from the employer's ability to establish payment rules based on prescription activity. Within the more tightly integrated program, the PBM can apply its standard adjudication and payment rules on non-network bills as if the bill was processed through the network. These rules can include adjudication against ICD-9 or NCCI codes. Bills that generate adjudication exceptions can be pre-authorized by adjusters using standard, in-network approval processes. Denied bills are processed by bill review with a denial code included on the explanation of review. Approved bills are processed according to normal bill review protocols.
Automated EDI Process