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Medication Monitoring Achieves Better Outcomes

Having the right patient medication monitoring tools is increasingly beneficial.
By: | September 2, 2014 • 5 min read

There are approximately three million workplace injuries in any given year. Many, if not the majority, involve the use of prescription medications and a significant portion of these medications is for pain. In fact, prescription medications are so prevalent in workers’ compensation that they account for 70% of total medical spend, with roughly one third being Schedule II opioids (Helios; NCCI; WCRI; et al.). According to the U.S. Drug Enforcement Administration (DEA), between the years of 1997 and 2007, the daily milligram per person use of prescription opioids in the United States rose 402%, increasing from an average of 74 mg to 369 mg. The Centers for Disease Control and Prevention (CDC) reports that, in 2012, health care providers wrote 259 million prescriptions—enough for every American adult to have a bottle of pills—and 46 people die every day from an overdose of prescription painkillers in the US. Suffice to say, the appropriate use of opioid analgesics continues to be a serious issue in the United States.

Stakeholders throughout the workers’ compensation industry are seeking solutions to bend the curve away from misuse and abuse and these concerning statistics. Change is happening: The American College of Occupational and Environmental Medicine (ACOEM) and the Work Loss Data Institute have published updated guidelines to promote more clinically appropriate use of opioids in the treatment of occupational injuries. State legislatures are implementing and enhancing prescription drug monitoring programs (PDMPs). The Food and Drug Association (FDA) is rescheduling medications. Pharmaceutical manufacturers are creating abuse-deterrent formulations. Meanwhile payers, generally in concert with their pharmacy benefit manager (PBM), are expending considerable effort to build global medication management programs that emphasize proactive utilization management to ensure injured workers are receiving the right medication at the right time.


A variety of factors can still influence the outcome of a workers’ compensation claim. Some are long-recognized for their affect on a claim; for example, body part, nature of injury, state of jurisdiction, and regulatory policy. In contrast, prescribing practices and physician demographics are perhaps a bit unexpected given the more contemporary data analysis showing their influence on outcomes. Such is the case for medication monitoring. Medication monitoring tools promote patient safety, confirm adherence, and identify potential high-risk, high-cost claims. Three of the more common medication monitoring tools include:

  • Urine Drug Testing (UDT) is an analysis of the injured worker’s urine that detects the presence or absence of a specified drug. Although it is not a diagnosis, UDT results are generally a reliable indicator of what is present (and what is not) in the injured body worker’s system. The knowledge gained through the testing helps to minimize risks for undesired consequences including misuse, abuse, and diversion of opioids. With this information in hand, adjustments to the medication therapy regimen or other intervention activities can occur. UDT can also be an agent of positive change, as monitoring often leads to behavior modification, whether in direct response to an unexpected testing result or from the sentinel effect of knowing that medication use is being monitored.
  • Medication Agreements or “Pain Contracts” signed by the injured worker and their prescribing doctor serve as a detailed and well-documented informed consent describing the risks and benefits associated with the use of prescription pain medications. Medication agreements help the prescribing doctor set expectations regarding the patient’s adherence to the prescribed medication therapy regimen. They serve as a means to facilitate care and provide for a way to document mutual understanding by clearly delineating the roles, responsibilities, and expectations of each party. Research also suggests that medication agreements promote safety and education as injured workers learn more about their therapy regimen, its risks, and benefits.
  • Pill Counts quantify adherence by comparing the number of doses remaining in a pill bottle with the number of doses that should remain based on prescription instructions. Most often, physicians request pill counts at random intervals or the physician may ask the injured worker to bring their medication to all appointments. As a monitoring tool, pill counts can be useful in confirming proper use, or conversely, diversion activities.

On a stand-alone basis, these tools rank high on individual merit. When used together as part of a consolidated medication management approach, their impact escalates quite favorably. The collective use of UDT, Medication Agreements, and pill counts enhance decision-making, eliminating gaps in understanding. Their use raises awareness of potential high-risk, high-cost situations. Moreover, when used in concert with a collaborative effort on the part of the payer, PBM, physician, and injured worker, they can improve communication and align objectives to mitigate misuse or abuse situations throughout the life of a claim.


Medication monitoring can achieve better outcomes

The vast majority of injured workers use medications as directed. Unfortunately, situations of misuse and abuse are far too common. Studies show a growing trend of discrepancies between the medication prescription and actual medication-regimen adherence when it comes to claimants on opioid therapy (Health Trends: Prescription Drug Monitoring Report, 2012). In response, payers, working alongside with their PBM and other stakeholders, are deploying medication monitoring tools with greater frequency to verify the injured worker is appropriately using their medications, particularly opioid analgesics. The good news is these efforts are working. Forty-five percent of patients with previously demonstrated aberrant drug-related behaviors were able to adhere to their medication regimens after management with drug testing or in combination with signed treatment agreements and multispecialty care (Laffer Associates and Millennium Research Institute, October 2011).

In our own studies, we have similarly found that clinical interventions performed in conjunction with medication monitoring tools such as UDT reduces utilization of high-risk medications in injured workers on chronic opioid therapy. Results showed there was a decrease in all measures of utilization, driven primarily by opioids (32% decrease) and benzodiazepines (51% decrease), as well as a 26% reduction in total utilization of all medications, regardless of drug class. This is proof positive that medication monitoring can be useful in achieving better outcomes.

This article was produced by Helios and not the Risk & Insurance® editorial team.

Helios, the new name for the powerful combination of Progressive Medical and PMSI, is bringing the focus of workers’ compensation and auto-no fault pharmacy benefit management, ancillary services, and settlement solutions back to where it belongs—the injured party.
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TPA Management

A Marriage of Compatibility

Employers must select the TPA best equipped to manage employees' health and well-being.
By: | September 2, 2014 • 9 min read
09012014_04_inDepth_series_700px525px_just_married PB

For all that modern client and third-party administrator (TPA) interaction depends on technology, compliance expertise, analytics and efficient claims administration, the most important factor in its success is still the partners’ compatibility, industry experts agree.


“It comes back to the relationship,” said Fred Hunt, active past president, Society of Professional Benefits Administrators (SPBA), a national association of TPA firms.

Since the client and TPA can interact daily on government compliance and such delicate issues as fluctuating reserves and claims escalation, “you have to like and trust your TPA,” Hunt said. “It’s like getting married.”

Scott P. Rogers, executive vice president, casualty operations, Sedgwick Claims Management Services Inc., agreed, since in many cases the self-insured employer, insurance collective, union or insurance carrier is entrusting the health of employees to a third party.

Scott P. Rogers, executive vice president, casualty operations, Sedgwick Claims Management Services Inc.,

Scott P. Rogers, executive vice president, casualty operations, Sedgwick Claims Management Services Inc.

“Companies hire TPAs when they believe the right partner can do a better job dealing with their most important assets, their employees, and their most important constituents, their customers,” he said.

Other than the bread-and-butter claims payment services, Hunt said, clients depend on “ERISA nerds” like his organization’s members to stay in compliance with complex, shape-shifting state and federal laws and regulations. “The TPA will call to say, ‘The IRS just issued this new reg, and we’re going to have to do this or that.’ ”

Companies may delegate because they don’t have in-house expertise, Hunt said, and penalties for violations can be devastating.

Size Matters

The right fit depends on a program customized to the company’s appetite for risk, cost threshold and company culture, said Rogers.

Size and scope matter also, said Richard Messick, specialist leader, Deloitte Consulting. “Larger companies may need a larger TPA with national or even global providers and regulatory experts. Smaller companies with only one or two local locations may do perfectly well with a regional TPA that doesn’t have the broad geographical reach of the larger companies.”

But Rogers said smaller clients, especially those who enhance their buying power by joining captive and affinity groups, such as public university insurance collectives, can benefit from the resources and expertise large TPAs may offer.

workinjury“The smaller clients get the same customization as the big companies,” he said, including access to a broad base of claims expertise, legislative updates and technology advancements. “It goes back to how the client and TPA partner together.”

Large or small, said Karen Stankevitz, managing director of consulting and analytics, Aptus Risk Solutions, all TPAs have strengths and weaknesses apart from the basic claims-payment services all provide.

“When you assemble your list of requirements in your request for proposals, don’t put down the basics,” she said. Instead, clients should figure out what they need beyond the basics, such as expertise and presence in all 50 jurisdictions or deep and broad contacts within the managed care community.


“Look at their differences,” Stankevitz said. Aptus, a consultant specializing in medical cost containment, claims and litigation management, sees prospective vendors’ strengths and differentiators emerge in sales presentations.

“The more a client asks a TPA to do outside their standard services, the harder it is for the TPA to perform optimally, and the more it will cost to get those services.”

When comparing sales presentations, Aptus suggests that clients may see desirable services one vendor provides that the client may not even have thought about requesting.

Regardless of their size and specialty, prospective clients and TPAs should meet and get to know each other rather than depend on a broker to vet candidates, SPBA’s Hunt said. If possible, clients should pay site visits to their prospective partners’ locations.

Fred Hunt, active past-president, Society of Professional Benefits Administrators

Fred Hunt, active past-president, Society of Professional Benefits Administrators

Brokers, however, can and do play an important role in partnering clients with the right TPA, said Srivatsan Sridharan, senior vice president, product development, Gallagher Bassett Services. The broker compares the client’s exposure data (such as industry, state and job type) against outcomes from various TPAs to find those with the best track record.

For example, if a client wants to contain medical management costs, the broker could collect data on its exposure in a given state for a given type of claim, then superimpose it on a TPA’s discounts, outcomes and penetration for those bill types in the states where the client operates.

When vetting candidates, said Ivan Dolowich, managing partner, Kaufman Dolowich & Voluck, which specializes in professional lines of business, “it’s good to look at claims systems,” some of which are highly automated and specialized. The industry was slow to invest in technology, he said, and TPAs’ systems are sometimes better than insurers’ legacy systems that they developed on their own and adapted to the type of claims they’re handling.

“At the end of the day, actions speak louder than words. Employers quickly recognize genuine performance.” — Scott P. Rogers, executive vice president, casualty operations, Sedgwick Claims Services Inc.

Not all due diligence is so high tech. In the course of a bidder’s conference, said Rogers, the prospective client and TPA may compare core values and decide their shared cultures bode well for the partnership.

“At the end of the day,” Rogers said, “actions speak louder than words. Employers quickly recognize genuine performance.”

To Bundle or Not to Bundle?

There are pros and cons to bundling and unbundling, said Stankevitz. A client has more buying power if it uses one TPA for multiple lines of business, and it may lose some negotiation leverage if it splits up the concentration. Reporting and analytics may also be better and easier with a single TPA.

“With all data in one system, running reports will be less complicated and more standardized,” she said.

But TPAs have different areas of expertise. “If you’re heavy in products claims,” she said, “you might want to assign that part of your business to a TPA that specializes in that line of business.” And if a client assigns different TPAs to different lines, it has a broader knowledge base, she said.

“If you have two TPAs, you have more resources to ask your questions. It opens up the networking,” she said.


A pilot program may be an option. “You can pilot a TPA in a state or a different line of business to get a sense of how they operate and manage your requests. It will give you a better sense of marketplace.”

Clients should be prepared to invest time and money in the process of unbundling a program, although with good planning the investment should provide returns. Transport operator FirstGroup America unbundled its bill review, pharmacy benefits management, field and case management, independent medical examinations, and occupational and physical therapy services in its self-insured program.

Two and a half years later, Frank Lott, the company’s corporate claims director, reported cost savings, and greater control and flexibility in the providers it chooses for its employees, and far greater transparency in its bill review.

During a Risk & Insurance® webinar, “Succeeding with an Unbundled Claims Management Approach,” Lott said that before unbundling, “We could never get a true understanding of our managed care costs.” After unbundling, the company found “a higher level of expertise in these areas, and they’ve become an extension of our team.”

However, these gains didn’t come without effort. “There’s an implementation phase,” Lott said, to allow each TPA on the team to “talk” to each other electronically.

“You have to look at connectivity. You have to look at how much time and money it will cost to build systems and interfaces. Can all the partners access the different systems?” There was also a training element that involved both the vendors and the TPA. “The goal was to not put additional work on the adjuster’s plate,” he said.

“A company needs to ask itself, ‘Do we have the internal resources to drive an effective program?’ ”

If a company decides to take on this process, said Suzanne Flynn, a webinar participant and senior vice president and risk management consultant for Wells Fargo Insurance Services, it should coincide with the initial execution or renewal of a TPA contract, some of which prohibit unbundling or impose punitive costs or fees, such as an exorbitant $9 per check writing fee.

“A company needs to ask itself, ‘Do we have the internal resources to drive an effective program?’”  —Frank Lott, corporate claims director, FirstGroup America

The contractual definition of “managed care” can also catch companies off guard, Flynn said, and may restrict programs without their administrators’ knowledge.
“Is it the traditional definition of fee schedule audit, preferred provider organization and utilization review? Or has the definition been expanded to include things like telephonic case management, field case management, pharmacies and/or durable medical equipment, thus becoming an even greater source of revenue for the entity?”

While some TPA contracts forbid unbundling, in other cases, clients are obliged to unbundle if their TPAs don’t service all their insurance lines, said Deloitte’s Messick. This is especially true for specialty liability lines, such as medical malpractice and directors’ and officers’ insurance.

Watertight Contract

After prospective clients and TPAs perform due diligence and decide they can work well together, they negotiate a contract that assigns their respective roles and responsibilities. The language in the contract should exceed the boilerplate contractual language of most service agreements, and include as much detail as possible, including the performance standards that define the parties’ respective roles, said Michael T. Griffin, partner, Edwards Wildman Palmer LLP in Hartford, Conn., who specializes in insurance law.

09012014_04_inDepth_series_450px_ sidebarFor example, he said, if the TPA will maintain a call center, the contract should detail the service standards the TPA must maintain. How many hours will it be open? How many people will staff it? How quickly will the staff answer phone calls? How quickly must claims be paid, or carriers and employees notified of their progress?

“If I’m a national carrier, the TPAs that represent me directly impact my reputation. I want their performance to reflect well on my brand,” he said.

Dolowich, of Kaufman Dolowich & Voluck, said he prefers contract language that defines authority lines and avoids the gray areas that can presage litigation. At what point does the TPA need the client’s approval to expand or clarify its reserve or settlement authority? Are the reserves adequate?


Those service level standards are often addressed in exhibits to the agreement, Griffin said, so if the parties want to tweak the details, they can modify the exhibit rather than amend the body of the agreement.

The contract should also provide for the eventual termination of the relationship, Griffin said, almost like a pre-nup.

“If you’re a carrier at the end of the relationship, the TPA is left with your information. How do you get it back?”

He encourages parties to think up-front about termination and transfer of data. How will information be presented? In hard copy? Pursuant to some system requirement? If costs will be incurred in the transfer of the information to its owner, who incurs those costs?

Susannah Levine writes about health care, education and technology. She can be reached at
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Needless MRIs

Early MRI Could Mean More Expensive Claims

Patients who received early MRI experienced higher costs and longer disability periods. Adherence to guidelines could solve the problem.
By: | August 29, 2014 • 3 minutes min read

In a study of work-related lower back pain claims, patients who received an early MRI had medical costs $12,000 higher and were on disability about 120 days longer than those that didn’t have the test, on average.


“One out of every five people that has fairly benign lower back pain gets an early MRI that they really shouldn’t get,” said Dr. Glenn Pransky, director of the Center for Disability research. “They then have a much higher risk to go on to receive a lot of treatments that aren’t necessarily helpful.”

Most likely, physicians have not been well-educated in the proper application of evidence-based medicine and the judicious use of MRIs in assessing back pain.” — Dr. Rupali Das, executive medical director of California’s Division of Workers’ Compensation.

Evidence-based guidelines state that MRI should not be indicated for non-specific, non-radicular lower back pain. And even in instances where “red flag” conditions exist – like severe traumatic injury or possibility for cancer or infection – guidelines suggest a month of conservative treatment before revisiting the need for an MRI.

“This study came from earlier work we had done, where we surveyed providers, giving them case scenarios and asking what they would do as their initial management of acute back pain in a workers’ comp setting,” said Barbara Webster, lead author of the recent study from the Liberty Mutual Research Institute for Safety on the early use of MRI. “And we were struck. Despite what the guidelines said, many of them would order an MRI.”

“Most likely, physicians have not been well-educated in the proper application of evidence-based medicine and the judicious use of MRIs in assessing back pain,” said Dr. Rupali Das, the executive medical director of California’s Division of Workers’ Compensation. “Physicians may be unaware of false positives and lack of specificity with MRIs. It may be easier to order a test than to counsel a patient on proper exercise and behavior. Patients also may play a role in demanding tests and some physicians may find it easier to comply with the request than to explain why a test is not needed or may actually be harmful.”

Those tendencies mean workers’ comp payers end up taking on costs for unnecessary tests and subsequent treatments dealing with issues unrelated to the original claim. That means more time away from work and more expensive claims. Workers’ comp payers may be missing an opportunity to catch inappropriate tests through utilization review, which would help produce better outcomes and contain costs.

“Our studies suggest that requests for early imaging tests should go through utilization review,” Webster said. “It’s likely that if providers are following OEM and ACOEM guidelines, it won’t be certified within the first 30 days.


Das suggested that payers start with “a carrot approach” by providing education on the existing guidelines for treatment, including initial management, and the proper indications that may warrant an early MRI.

“With the involvement of a medical director, the usage of MRIs can be measured, and inappropriate usage assessed,” he said. “Outreach and appropriate intervention should be directed at providers with a pattern of ordering tests inappropriately.”

Fee-for service payment models may incentivize physicians to order more tests, but quality and outcome-based payment proposed by the Affordable Care Act should dampen that trend.

“Many organizations are now educating their members about the proper use of radiologic tests, including MRIs,” Das said. “Hopefully younger physicians will be better educated about evidence-based practices.

MRIs can reveal age-related abnormalities, like compressed and degenerated discs in the spine, that may have nothing to do with what’s causing the back pain, Webster and Pransky said.

“In one study, MRIs found significant abnormalities in 60 percent of people sampled,” Pransky said. “Human tendency is to point to the abnormality as the cause of the pain, and suggest surgery or injection to treat it. It can be hard to dissuade people from thinking that’s not the source of the problem.”

“The natural history of many conditions causing lower back pain is that half of them will resolve themselves without the need for further imaging or surgery,” Webster said.

Katie Siegel is a staff writer at Risk & Insurance®. She can be reached at
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