PMSI Program Reduces Fraud, Waste and Abuse in Workers’ Compensation

Share Article

Fraud, waste and abuse of prescription medications is a major issue throughout the entire healthcare system, especially the workers' compensation industry. PMSI's Fraud, Waste and Abuse program integrates clinical strategies to identify and intervene on high-risk behaviors in workers' compensation claims.

PMSI’s Fraud, Waste and Abuse program is designed to detect and act upon potential, high-risk behaviors in three communities of interest: injured workers, prescribers and dispensers.

PMSI, one of the nation’s largest and most experienced companies focused on workers’ compensation, announced initial results from its Fraud, Waste and Abuse Program, a proprietary program integrating clinical strategies to identify and intervene on high-risk behaviors in workers’ compensation claims. To date, PMSI’s Fraud Waste and Abuse program has delivered a 15% reduction in prescription spend when high-risk claims are identified and intervened upon; a 90% conversion rate from multiple prescribers to one lead prescriber, and; an 80% acceptance rate of PMSI’s clinical recommendations after peer-to-peer outreach is completed with the treating provider.

Injured workers enter the workers’ compensation system due to some type of physical injury, which usually requires treatment for pain. PMSI’s 2012 Annual Drug Trends Report shows that 75% of total pharmacy spend is related to medications used for the treatment of pain—narcotic analgesics (or Schedule II opioids) comprising almost 34% of this total drug spend. A report in the 2009 Journal of the International Association for the Study of Pain stated that when a workers’ compensation claim involved Schedule II opioids, the claim costs averaged nearly $20,000 more than claims without opioids.

“While the proper use of opioids can be very effective in the treatment of pain, improper use can lead to serious issues with fraud, waste and abuse,” said Jay Krueger, PMSI’s Chief Strategy and Client Services Officer. “The conflicting problems of unrelenting chronic pain and prescription drug abuse directly and indirectly involve many stakeholders, not just the injured worker. PMSI’s Fraud, Waste and Abuse program is designed to detect and act upon potential, high-risk behaviors in three communities of interest: injured workers, prescribers and dispensers.”

PMSI’s multi-tiered Fraud, Waste and Abuse specialty program combines its proven clinical programs with an analysis of physician and pharmacy behavior to identify, alert, act and monitor potential high-risk behaviors from all prescribers, dispensers and injured workers. The program looks at the following indicators to identify targeted claims for intervention:
                - High levels of narcotic prescribing, dispensing and utilization

  •      Utilizing multiple sources of prescriptions and medications
  •     
  • Early refills of targeted medications
  •     
  • Long-term use of targeted medications
  •     
  • High levels of physician dispensing
  •     
  • Unnecessary brand medication prescribing and utilization
  •     
  • High prescribing and utilization of compound medications
  •     
  • Providers and pharmacies that have been sanctioned for actions related to fraud and abuse

“PMSI’s MedAssess clinical solution has proven effective in preventing fraudulent, wasteful and abusive activities in pharmacotherapy,” said Dr. Maria Sciame, Executive Director of Clinical Services for PMSI. “With over 35 years of industry experience, a database of millions of workers’ compensation transactions and a team of clinical specialists, PMSI is able to accurately identify potentially fraudulent, wasteful or abusive activities and facilitate interventions to support prevention and thwart fraud, waste and abuse.”

PMSI subject matter experts address the topic of fraud, waste and abuse in workers’ compensation in a short ExpertInsights video on PMSI TV, which can be found at http://www.pmsionline.com/ExpertInsights.

About PMSI:
Founded in 1976, PMSI is a leader in developing solutions to control the growth of medical costs in workers’ compensation. As one of the nation’s largest and most experienced companies focused on workers’ compensation and liability markets, we deliver proven solutions for cost containment across the claims lifecycle. PMSI’s solutions for Pharmacy, Medical Services and Equipment, and Settlement Solutions deliver quantifiable results and improve the quality of care for injured workers. We provide our customers with the innovation, focus, expertise, analytics and technology needed to successfully deliver workers’ compensation benefits. For more information, visit http://www.pmsionline.com or call 877.ASK.PMSI.
# # #

Share article on social media or email:

View article via:

Pdf Print

Contact Author

Jan Luongo, APR, CPRC
PMSI, Inc.
(813) 318-6810
Email >
Visit website