Workers’ Compensation Cost Management » PRIUM Medical Cost Management Services

By: PRIUM  09-12-2011
Keywords: drug


All PRIUM pharmacy reviews are conducted in a peer-to-peer, collegial environment utilizing active-practicing physicians from our nationwide network in coordination with all pertinent treating physicians.  One of the most important aspects of the review process that PRIUM excels in is securing this discussion and the subsequent agreement to regimen change. Our medical doctors adhere to evidence-based medicine (EBM) as well as official disability guidelines (ODG). Therapeutic equivalent conversion is embedded into PRIUM’s pharmacy reviews whereas each medication is evaluated for potential conversion to a generic, therapeutic, or pharmaceutical equivalent.

We firmly believe that the most inexpensive drug is the one not prescribed, but also understand and take into consideration evidential necessity.

Qualified Medical Intervention Program

Physician Pharmaceutical Review

PRIUM’s Physician Pharmaceutical Review (PPR) Program was developed to mitigate innapropriate drug regimens associated with claims within the Workers’ Compensation industry. The program utilizes a proactive and collegial engagement with the injured worker’s prescribing physician(s) to ensure the drug regimen component of their treatment is medically necessary, appropriate, and related to the defined Workers’ Compensation claim.


  • PRIUM’s focus remains on ensuring only medically appropriate drugs are being used for the injured worker’s care. 
  • Although placing a patient in our PBM is not mandatory, our best documented successes have come when we have the capacity to monitor and enforce the agreed-upon drug regimen. 
  • Customer service. The delivery of a PPR report is always accompanied by contact from your devoted account executive. This executive will initially go over the report with the customer, and answer any questions that may arise. Your assigned account executive will also be the singular point of contact with PRIUM throughout the case-management process, providing the customer with informative reports until all objectives laid out in the initial report are completed.

Pharmaceutical Prior Authorization (PPA)  

This review incorporates physician oversight into the Prior Auth process, either as an escalation point from the pharmacy’s POS, before the script is filled, or retrospectively to address future scripts. The scope of this review typically involves just one drug. PPAs are turned around in two business days. 

Physician Pharmaceutical Intervention (PPI)

This review can be seen as an early intervention PPR. A PPI helps to get in front of a drug regimen before it becomes problematic.

Comprehensive Clinical Assessment (CCA)

This review evaluates the entire medical treatment plan, including the drug regimen, to establish a baseline for ongoing care. It is quite similar to the Physician-DUR, but it includes the non-pharmacological treatment plan as well.

Medicare Set-Aside Clinical Reviews (MSA-CR)


Prescription drugs are a disproportionate component of the MSA (Medicare Set-Aside) process. The MSA Clinical Review (MSA-CR) is provided in support of the MSA settlement process to document the most appropriate current and long-term pain management regimen in a way that the Centers for Medicare & Medicaid Services (CMS) will approve, representing a consensus among all parties on the best approach.

CMS imposes strict guidelines in regards to evidential proof as it pertains to making these recommendations. CMS requires evidence, not promises.

We recommend 4 to 6 months of evidentiary proof of changes of treatment before submitting to CMS.

The Process

Because CMS now requires evidentiary proof instead of promises for future changes, it is imperative that when PRIUM is successful in gaining discussion and agreement with the treatment providers, the changes are actually implemented. This cannot be left to the discretion of the treatment provider(s). Despite their best intentions the changes might be overlooked. PRIUM has a program to enforce these changes, and strongly recommends that a WCMSA not be submitted to CMS until all inappropriate and unrelated drugs have been discontinued (through the weaning process). The program consists of three steps:

  1. Discussion. PRIUM’s physician initiates a collegial and professional discussion with each prescribing physician about their role in the injured worker’s drug regimen, using Evidence-Based Medicine (EBM), pertinent medical/claims records and educational/clinical experience to mutually identify what drugs should be used. If an agreement is reached on modifications to the regimen, acknowledgment in writing will be secured. The final report details the full recommendations, how they relate to EBM, and the response from the prescribing physician.
  2. Enforcement. The injured worker is added to PRIUM’s PBM services so a formulary can be implemented to require Prior Authorizations of all drugs that were deemed by the report to be inappropriate or unrelated. Network discounts are incorporated to ensure the best possible price for the drugs that are approved. NOTE: If the customer already has a PBM in place, PRIUM will work with that PBM to implement the appropriate closed formulary. 
  3. Oversight. PRIUM’s Case Management group monitors the drug transactions, especially those that were agreed upon for discontinuance or weaning. If the prescription behavior does not match the modified plan, the prescribing physician will be contacted for follow-up. 

Compound Drug Management Program

Compound Drug Review

Compound drugs, which should be prescribed by a doctor, are prepared by a pharmacist who mixes or adjusts drug ingredients to customize a medication to meet the unique needs of a patient. Compound drugs often have the same active ingredients as brand-name and generic prescription drugs but can differ in strength and be provided in forms (i.e. lozenge, syrup, topical) not usually available. The introduction of compound drugs to a drug regimen can be for medically necessary reasons, such as to avoid a nonessential ingredient to which the patient is allergic or to obtain a more precise dosage. The advent of mass production of prescription drugs has changed the compounding process from mainstream into a highly customized and infrequent practice.

The Issue

The use of compound drugs in Workers’ Compensation has become a problem for two reasons:

  1. Overpriced. The filling pharmacy (or physician’s office, if dispensed there) will sometimes create a price that does not accurately reflect the proportion of each ingredient and its contribution to the overall cost. To maximize profits, the most expensive ingredient is often charged at full-price when it may only be 10-15% of the complete compound. 
  2. Unnecessary. Compounds are sometimes used when typical prescription drugs would be sufficient or even more effective. In this case, the higher the cost of the compound drug is simply not justified. 

The Program

PRIUM developed the Compound Drug Management Program to help address these two primary issues. The process is simple, turnkey and offers a high return on investment because of the shared risk involved. This program can be utilized in any jurisdiction. However, the scope of the compound drug issue and the statutory report provided in California allows this program to perform particularly well in that state.

Pharmacy Benefit Management

The primary responsibility of a PBM (pharmacy benefit management) company is to process and pay for prescription drug claims, negotiate discounts and rebates, implement and maintain formularies, and establish a network of pharmacies for cost control. Since Utilization Management is in our DNA, our additional focus is on the most appropriate use of pain management for insured workers. Not only is this best for the patient’s health, it is also typically less expensive in the long term. PRIUM’s perspective is that it is better to focus on management of the overall medication regimen than per-pill costs. The most inexpensive drug is the one not prescribed.

One of the best uses of our PBM is in correlation with our Physician-DUR and MSA-CR programs. Enrolling claimants into our PBM allows us to better monitor and enforce the recommendations made within these reports.

Keywords: drug

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