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PBMs and Legacy Work Comp Claims

11 Feb, 2020 WorkersCompensation.com

                               

Employers, state funds, and insurers are focusing more and more on closing old claims; the most successful ones are partnering with their Pharmacy Benefit Managers. 

The logic is clear – the older and more costly the claim, the greater the percentage of spend is for drugs (except for those cat claims needing long-term home health/facility care). 

And, the higher the reserves, the greater the percentage of those reserves is for drugs (except for those cat claims needing long-term home health/facility care). 

Both graphs from NCCI; Medical Services by Size of Claim—2011 Update.

While some very large payers (e.g. Ohio BWC, Washington L&I, State Fund of California and Sedgwick) have strong clinical pharmacy capabilities, most payers don’t.

If you are looking to reduce your claims inventory, partnering with a PBM with: 

  • real expertise in analyzing legacy claim information,
  • very strong clinical capabilities, and
  • a demonstrated ability to help manage legacy claims is mandatory.

What does this mean for you?

Find out if your PBM has these capabilities – and ask how they can help you. If you aren’t impressed, find another PBM.

By Joe Paduda

Courtesy of Managed Care Matters

 

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