Opioid Management

Take a Proactive Approach to Reduce Opioid Liability Risk

Payers are increasingly being held responsible for addiction and overdoses related to opioid pain medications prescribed for occupational injuries.
By: | August 21, 2015 • 3 min read
bottle of pills

Workers’ comp payers are increasingly on the hook for problems related to opioids prescribed for injured workers, according to a new report. The National Safety Council examined several recent cases and issued a warning and suggestions for employers and insurers to take steps to protect injured workers and themselves.


“Recent court decisions have determined that in certain circumstances, overdoses suffered by injured workers from opioid pain medications prescribed for occupational injuries are compensable by the workers’ compensation insurer,” the report noted. “Employers and their workers’ compensation insurance carrier have been ordered to pay for detoxification and medical-assisted treatment services as well as death benefits to surviving family.”

The NSC cited more than two dozen cases from state appellate or state Supreme Court decisions between January 2008 and March 31, 2015. “These cases demonstrate that it is not a regional issue but a national problem meriting employer and workers’ compensation program action,” the report said. “The courts relied on several key legal concepts.”

Proximate cause, for example, is identified as “any legally recognizable set of facts which, in natural or probable sequence, produced the individual’s injury.” If a worker slipped on spilled water at work and sustained an injury, the spilled water is the proximate cause of the injury.

The “chain of causation” determines whether any injury after the original is related to the workplace injury. Sometimes a separate action by the injured worker can be considered an independent intervening act, or superseding cause. In such a case, the intervening act breaks the chain of causation and ends the liability for the workplace injury.

“For the cases reviewed in this paper, the chain of causation is clear,” the report said. “A workplace injury occurred. The injured worker received treatment that included prescription pain medications and subsequently died of an opioid-related prescription drug overdose. The legal question at the center of all these cases is whether an intervening action broke the chain of causation to the workplace injury.”

States differ in their workers’ comp laws and rules of evidence. Nevertheless, in the majority of cases noted in the report overdose deaths of injured workers may be compensable “even when the medication is not taken as prescribed, taken with alcohol or inappropriately prescribed.”

Employers and insurers are advised to reduce their risks and potential compensable costs related to the use of opioid pain medications in workers’ comp claims by:


  • Requiring workers’ compensation and network providers to use opioid prescribing guidelines issued by the American College of Occupational and Environmental Medicine. These include guidelines on opioid prescribing thresholds and recommend precautions for the prescribing provider. Among the precautions are undertaking thorough patient histories with a more detailed screening if the treatment is to continue beyond two weeks, urine drug monitoring, checking the state prescription monitoring database, avoiding co-prescribing benzodiazepines with opioids, and discontinuing treatment when patients have reached meaningful functional recovery.
  • Using caution and requiring prior approval for the use of methadone to treat chronic noncancer pain.
  • Screening injured workers for depression, mental health conditions, and current or prior substance use.
  • Requiring all pharmaceuticals be purchased and managed by a pharmacy benefit manager.
  • Educating all workers about the hazards associated with prescription pain medication use. “Many workers do not understand the unique risks and dangers posed by opioid pain medications,” the report said.
Nancy Grover is the president of NMG Consulting and the Editor of Workers' Compensation Report, a publication of our parent company, LRP Publications. She can be reached at [email protected]
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Opioid Management

Closed Formularies a Useful Tool

Several states have implemented closed formularies in their workers’ comp systems, and are reporting positive results in their efforts to address opioid abuse.
By: | August 10, 2015 • 5 min read

“Many workers who have taken opioid painkillers following on-the-job injuries have become addicted, suffered additional injuries or fatally overdosed,” according to the National Safety Council. “As a result, courts have ordered employers and workers’ compensation insurance carriers to pay for detoxification, medication-assisted treatment and death benefits to surviving family members.”


The situation has escalated to the point where the NSC is calling on employers to create policies around the use of opioids. Workers’ comp stakeholders are looking to additional strategies to address the misuse of opioids, including closed pharmacy formularies.

“A formulary is an approved medication list often based on clinical review of evidence-based medicine and both nationally and regionally approved medical guidelines,” according to a recent drug trend report from pharmacy benefit manager Helios. PBMs have used formularies for a number of years. Now states have begun to adopt them for their workers’ comp systems.

“Basically there are two types [of closed formularies],” said Brian Allen, vice president of government affairs for Helios. “There is the Texas style, which is more inclusive, where there is a list of drugs not included, and all other medications are included. Washington and Ohio have a type that is a preferred medication list, and providers prescribe off of that list. It’s a narrower list. Both [types] work well.”

“It is to workers’ comp what a hammer is to construction. It will be used daily and will have an impact.” — Brian Allen, vice president, government affairs, Helios

Several states have implemented closed formularies in their workers’ comp systems, and others are considering their use. In addition to Texas, Oklahoma, Washington, and Ohio, the idea is also being considered in Arkansas, California, North Carolina, and Tennessee. Maine, Michigan, and South Carolina are said to be interested. Louisiana’s Legislature failed to pass a formulary proposal, but state regulators have indicated they will begin developing a rule. Early results are looking positive from the states that have implemented the formularies.

“We’ve seen a lot of numbers in our drug trends report,” said Nichole Wilson, director of pharmacy product development for Coventry First Script. “In general, the implementation (of closed formularies) will typically lead to a reduction in narcotics opioids utilization; a reduction in ‘N’ list drugs; compounds typically decrease, depending on the rules. They basically target some of those high-dollar, riskier drugs.”

‘N’ drugs are those included on a list of medications that will not be approved without prior authorization. They are typically taken from the Official Disability Guidelines — Treatment in Workers’ Comp Appendix A. Drugs that are not on the ‘N’ list and have been approved by the Food and Drug Administration are generally allowed for injured workers with some exceptions.


The use of formularies varies among the states using them. But experts say a formulary can lead to better outcomes for injured workers and lower costs for payers.

“Is it a panacea? No. Is it a nice tool to have on the tool belt? Yes,” Allen said. “It is to workers’ comp what a hammer is to construction. It will be used daily and will have an impact.”

Nuances of Formularies

Texas adopted a closed formulary in 2011. A 2014 report from the Texas Division of Workers’ Compensation said the cost to the system for ‘N’ drugs had fallen by 82 percent; the total number of prescriptions for ‘N’ drugs was reduced by 74 percent; and there were 66 percent fewer injured workers receiving ‘N’ drugs.

But concerns in the Texas formulary have come to light in the intervening years, and industry stakeholders are advising other states to take note. The biggest centers on compound medications, which are being easily approved.

“Typically, there would be a mix of several drugs to create a topical formula,” explained Donald Lipsy, manager of regulatory, communications, and compliance at First Script. “If they include one or more on the ‘N’ list, they require prior authorization. If not, those are allowed to go through.”

Oklahoma, which implemented its closed formulary last year, required all compounds to be treated like ‘N’ list drugs. Other states may take the same approach.

Future Trends

Formularies are most successful when multiple parties to the workers’ comp system are involved in their creation, the experts say. California, for example, is taking that approach.

“They are creating a mandate for a formulary and mandate of a committee of medical people, including pharmacists, to help set up the formulary and the variances,” Lipsy said.

Both Lipsy and Allen agree that when formularies are developed with the help of PBMs, physicians, and nurses working together, there is a better chance of getting the right drug to the right person at the right time. One of the values of formularies is the empowerment it gives the parties involved with workers’ comp claims, especially physicians.

“Since the incorporation of the Affordable Care Act some of a [physician’s] reimbursement is tired to patient satisfaction and that is starting to impact workers’ compensation as well. With that, if you have to say no to a patient it would be bad,” Allen said. “Physicians have said, ‘I’ve had people ask for medications and I don’t want to say no, but now I can say it’s not me [saying no] it’s the state.’ If the state says so, it kind of takes the physician off the hook.”


The experts believe formularies (when used with other tools to reduce overutilization and costs of prescriptions) can add great value. They say many jurisdictions are taking a closer look.

“What’s interesting is when Texas implemented and published the results [of its formulary] a lot of places paid attention,” Wilson said. “I have a feeling more and more states will be considering them because of decreases in prices and utilization. I have a feeling we will see that trend.”

Nancy Grover is the president of NMG Consulting and the Editor of Workers' Compensation Report, a publication of our parent company, LRP Publications. She can be reached at [email protected]
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Sponsored: Helmsman Management Services

The Quality Assurance Journey

Helmsman TPA is changing the claims management game with their enhanced quality assurance process, a welcome departure from the industry standard checklist approach.
By: | August 3, 2015 • 5 min read

Not too long ago, if you were planning a trip, you would buy a map or an atlas and draw out the route you would take. If you continued to drive this route repeatedly, you might discover better ways to avoid a heavily congested area or take advantage of a new highway.

Similarly, a third party administrator (TPA) draws on years of experience to develop best practices for claims handling, discovering better routes and avoiding areas of delay. Payers trust their TPA to formalize these best practices, and to develop a Quality Assurance (QA) program that helps ensure claims are effectively managed. Like a roadmap, a QA program tracks the journey to the desired destination.

Mark Siciliano defines a quality assurance program.

With today’s technology, a cumbersome map is replaced with a GPS; just follow the step-by-step instructions. Sometimes the technology works flawlessly, and other times, it doesn’t deliver the best route.

Likewise, many QA programs have developed a checklist mentality, listing the steps to take. Such QA programs typically involve a small team reviewing a limited number of claims to ensure that key standards are consistently applied. While important, this doesn’t necessarily guarantee claims are optimally handled, or uncover ways to improve claim workflows and performance.

Mark Siciliano explains how Helmsman’s QA approach differs from the industry’s standard “checklist” mentality.

A New Process

Helmsman Management Services LLC, a third-party claims administrator and a member of Liberty Mutual Insurance, began to re-examine its QA program with the help of its clients several years ago. In doing so, they developed a new methodology that is a welcome departure from robotic checklist behavior.


“Our QA program dives deeper to find actionable ways we can improve claims outcomes, the performance of claims professionals, and the entire claims management process,” noted Mark Siciliano, vice president and managing director of Helmsman Management Services. “We conduct more in-depth reviews on a higher volume of claims – more than 80,000 each year – at key points in the lifecycle. We involve over 800 field claims professionals and engage individual claims handlers and their managers through an online dashboard that reports performance and highlights opportunities to improve performance through additional training and coaching.”

Mark Siciliano discusses the Helmsman approach to quality assurance.

The new approach to QA was successful, enabling Helmsman to improve the overall quality of its clients’ claims by eight points in 2014. In fact, 92.7 percent of the claims Helmsman managed met or exceeded the TPA’s service standards in the fourth quarter of 2014, up from 84.5 percent in the first quarter of that year.

“Re-engineering our QA program and moving it beyond the standard industry checklist approach took our claims management from really good to great,” said Siciliano. “And, it is helping us drive further improvements.”

One of the reasons for that improvement is Helmsman’s QA process keeps adjustors focused on what works best.

“We looked at the common characteristics of really great outcomes and worked backwards,” said Siciliano. “We found that when our claims professionals start with an empathetic approach, they are better able to connect with the injured employee and deliver better outcomes, both for the claimant and her or his employer.”

Like blindly following GPS instructions, a claims professional can easily fall into a pattern of completing tasks and forget that an injured person may be experiencing a very challenging time in their life. Helmsman trains its claims professionals to treat the injured worker as if they are dealing with a family member. It’s not just asking questions and moving through a checklist; it’s answering an injured worker’s questions, providing important information, and doing so with a level of compassion.

Once a conversation has begun and the injured worker is more at ease, the claims professional can ask questions beyond what might be in the process to really understand the injury, the individual, and the claim, and to find that best route to the ultimate destination of return to work. This inquisitive nature of the claims professional also allows for early discovery of any specific challenges in the claim – such as co-morbid conditions or psycho-social issues – paving the way for intervention to get the claim back on track.

“We call it humanistic common sense,” said Siciliano. “We know we have to ask the tough questions and protect our clients’ financial interests, but when we do so through a positive and supportive lens, it permeates throughout the entire process, facilitating the journey.”

Building a relationship with medical providers using this same approach can also assist the claim.

Helmsman_BrandedContent“Re-engineering our QA program and moving it beyond the standard industry checklist approach took our claims management from really good to great. And, it is helping us drive further improvements.”
— Mark Siciliano, Vice President and Managing Director, Helmsman Management Services

In the case of light duty restrictions, instead of ‘check’ and move on after the initial call with the treating physician, Helmsman asks for more details on what the injured worker can do, and helps the physician understand the claimant’s duties and the temporary jobs available. Helmsman might ask the doctor to join them for a site visit to better understand the work environment.

As a result, light duty jobs become gainful and meaningful work for the injured worker because they are tailored to their capabilities.

“We’re not just asking for medical information and work capacity; we’re actually working with our clients and the physicians to create a return-to-work environment that works for the injured worker, employer, and physician,” said Siciliano.


Evolution of Change

Helmsman_BrandedContentA QA program that delivers a high level of value to the employer and improves outcomes for the injured worker is just the beginning. QA is more than a program—it’s a process. Quality assurance programs are critical for tracking and improving performance. It’s a continuous cycle of training, learning, client feedback, and process improvement.

“Our enhanced QA program helps us better service our clients, but we know it’s an ongoing process,” said Siciliano. “Our continuous improvement process is built around the investment that we put in our people, systems, and technology. It’s also response to the changing landscapes around us, and how well we adapt to them.”

Mark Siciliano describes characteristics of effective quality assurance programs.

As a result, quality assurance programs are not working towards just a destination; they’re working towards the evolution of change, and how risk managers, brokers, and TPAs respond to it. The QA process becomes that journey.



This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Helmsman Management Services. The editorial staff of Risk & Insurance had no role in its preparation.

Helmsman Management Services (HMS) helps better control the total cost of risk by delivering superior outcomes for workers compensation, general liability and commercial auto claims. The third party claims administrator – a member of Liberty Mutual Insurance – delivers better outcomes by blending the strength and innovation of a major carrier with the flexibility of an independent TPA.
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