After all, reducing costs and ensuring the best possible care are the two primary drivers for creating a provider network in the first place (there are others, but the network is the backbone of any pharmacy benefits manager strategy).
With the right safeguards in place, however, out of network care--prescription drugs in particular--can be controlled and costs can be reduced.
"Patients going out of network for their prescription drugs is a major pain point for payers in workers compensation," says Tron Emptage, RPh, MA, a pharmacist and vice-president with Westerville, Ohio-based Progressive Medical, a workers' compensation pharmacy benefits manager (PBM). "For example, when you are talking about prescription drugs, you can send the employees a drug card, much like any health benefit card, but if the patients don't have it with them, the prescription will be billed at the full price. As a result, payers lose their discount."
Emptage, in fact, points out that patients going out-of-network, by definition, has historically and arguably been the biggest challenge when it comes to controlling prescription drug costs--everything flows from the network.
"Out of network bills signals a lack of control for carriers and payors," he says. "And it will have a major impact on the total claim costs and care. From the PBM perspective, we are trying to pull it all together. Having out of network transactions means the PBM may not be capturing critical data. So not only is there the lost discount and provider costs are higher, but valuable utilization data may not be available for review and incorporation into the adjudication process.
"As with anything, whenever you lose control and services are approved and paid for, it's much harder to stop the ball from rolling," he says. "It is easier to capture data and monitor a treatment path when an adjustor has the information upfront. So it's critical to keep costs and care within the network from the start."
He says, for example, that by capturing that data through in-network utilization, claim adjustors can ask the right questions, with the result being better outcomes through monitoring the treatment plan and guidelines.
In many cases, the main cause of a patient going out of network can be the result of nothing more than an injured worker, say with a sprained ankle, seeing their primary care physician who sends the patient out to buy crutches and/or fill a prescription. The injured worker might do those early treatment steps prior to contacting their employer or setting up a claim, which means they are typically done out of network. Many times, it's accidental and innocent, as they are just doing what their doctor told them to do. Only when the patient finally reports to their employer about the injury sustained at work does the network come into play.
"The critical thing is doing whatever needs to be done to get the patient into the network as early on in the life of the claim as possible," Emptage says. Most companies today have a "first report of injury" process in place and on the prescription drug side, this first step in the claim can be the first step to capturing prescription data and the first step in getting network information to the claimant.
"You need the pharmacy network information given right up front, as close to the FROI as possible. This information assists the claimant in getting more medical services in network," he says. "The crutches, the ice pack or and the medicine--once in-network give more information to the case handler on the claim, often allowing for better outcomes due to having more information up front."
In some situations, claimants may not understand the drug card process, and either don't use it or in some circumstances, choose not to use it or to follow the directed plan. And since some states' regulations do not allow for direction of care the employees with workers compensation claims, are not always able to use a medication card or to use an insurance carrier's medical network for their needs. From a control point of view, the network penetration is harder to achieve and often increases costs of medical through direct costs and administrative burden. Both pharmacy and physical therapy can be the most problematic networks as it relates to out of network costs and care, before the network process takes over. Emptage explains the difference is that PBMs don't have the chance to change the price of a prescription drug after it has been dispensed through networked or bill review relationships as exists in physical therapy.
"In a high fee schedule state, the costs can skyrocket," he says, adding that the majority of invoices will be priced at these rates.
So what can a carrier/payer do if they can't get the network in play from the start? For one, they can expect their PBM to reach out directly to providers, to make a strong effort to "bring in" those bills.
In Progressive Medical's case, they offer a program called NetworkAssist, which brings both paper and electronic claims/bills into the network, allowing Progressive to review pharmacy utilization patterns by which it can, at the point of sale, alert its customers as to what is happening on the files regarding network utilization.
Basically, NetworkAssist focuses on out-of-network pharmacy invoices. Through it, Progressive Medical can provide recommendations for payment on out-of-network invoices, which are run through Progressive Medical's medication plans or business strategies, and then convert to the appropriate state fee schedule, Progressive Medical UC&R or contracted rate. After receipt of the original invoice, a recommendation is provided to the client for the payment amount to the pharmacy.
Basically, the process begins when an injured party has an out-of-network prescription invoice, which is then submitted to a payor client for reimbursement either directly by the pharmacy or by a third party agent. The client sends out of network prescription invoices to Progressive Medical either by fax, e-mail, EDI or in hardcopy form, and Progressive Medical conducts systematic checks for existing claims for an injured party.
If there are no existing claims, the prescription will process through Progressive Medical's medication plans and business rules. The information is then forwarded to Progressive Medical's Client Services team to follow procedures for setting up the injured party claim and for issuing a retail drug card. If a claim exists for the injured party, the prescription will process through the injured party's current network coverage. Progressive Medical's Client Services team is alerted to repeat out-of-network prescription fills in order to initiate contact with the injured party and change coverage where appropriate
Progressive Medical will generate an Explanation of Charges and Reimbursement (EOCR) per payor invoice received, showing a recommendation for payment or denial for service. The EOCR is attached to the original invoice and returned to the client.
Emptage says that the percentage of out of network bills that can be run through NetworkAssist is very carrier/payor specific, with NetworkAssist program clients seeing as high as 80 percent of their bills sent through the process. Most of all, Progressive Medical's initiatives are focused on bringing out of network claimants into the network by utilizing and strengthening relationships with third party agents, out of network physicians and pharmacies.
"If we can bring them into a partnership, it allows us to get utilization data back into the network," he says. "NetworkAssist has proven very effective at detecting and lowering costs on both out of network and in-network billing. Our goal is to always try to secure cost reduction for the client, but to make sure that patients receive the most appropriate and optimal care as well."
(The above piece is part of our continuing Insights series designed to highlight key products and services to our readers. This paid-for Insights was written and edited by Risk & Insurance®
on behalf of our marketing partner. Additional Insights can
be found on our Web site at www.riskandinsurance.com/.)
February 3, 2010
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