8 Reasons Pharmacy Benefits Managers Are Integral to the Workers’ Compensation Process
Sustaining an injury in the workplace can be traumatic and debilitating, even for the healthiest employee. Unfortunately, utilizing pharmacy benefits is often difficult for injured workers, especially if they’ve never had to claim workers’ compensation. This difficulty can be avoided when an injured employee’s insurance company and pharmacy benefit managers (PBM) partner seamlessly. If you have ever wondered why PBMs are integral to the workers’ compensation process, here are eight reasons.
1. Reduced Claim Time
PBMs can have a considerable impact on the time spent by examiners and adjusters. Pharmacy benefits managers with significant experience can reduce the administrative burden placed on examiners and adjusters by acting as third-party claims administrators. By coordinating directly with a claimant’s health insurance company, a third-party administrator lets examiners and adjusters focus their time on adjudicating claims productively and efficiently, removing the need for them to spend their time coordinating benefits relating to deductibles and copays.
2. Discounted Medications and Pharmaceutical Services
Companies that specialize in providing workers’ compensation PBM typically negotiate discounted rates on various pharmaceutical services for insurance companies and their claimants. These discounted rates are provided via a network of pharmaceutical service providers that an insurance company’s enrollees will have access to for their claim-related prescriptions.
3. Pre-Authorization
Pharmacy benefit managers have the ability to identify the appropriateness of various prescription drugs for the claimants of the insurance company they partner with. The pre-authorization process results in a PBM ensuring all prescriptions billed under a particular claim are related to that claim. Once the PBM is sure the claim is injury-related, a claimant typically pays no out-of-pocket costs for their prescription. PBMs can also evaluate if a medication must be dispensed as written or whether a generic prescription is available at a lower cost.
4. Compound Medication Billing
Compound medication billing can be complicated. Pharmacies equipped to mix various pharmaceutical ingredients of medications specifically for a single patient are referred to as compounding pharmacies. Compound medications are evaluated and billed differently than other types of medications since multiple medications are utilized in the formula, in addition to specialized equipment and increased pharmacy labor costs. PBMs can use their own fee schedule to prevent insurance companies from having to shoulder unnecessarily high costs.
5. Additional Pharmacy Benefits
PBMs almost always offer additional benefits intended to boost claimant satisfaction, such as home delivery services. Such a benefit can be especially helpful if a claimant sustains a catastrophic injury while working and is unable to get to a pharmacy to pick up their prescription. Additional benefits improve customer satisfaction rates with their insurance companies while making their lives easier.
6. Claimant Support
Suffering from a complex health condition can be stressful and time-consuming. Fortunately, PBMs can provide personalized care to help severely injured patients manage their therapy. PBMs typically utilize a team of specialty pharmacists and nurses who are available to offer support and answer medication-related questions. These professionals are usually trained in complex medical conditions, so they can relate to patients. Patients are even able to receive refill reminders, as well as assistance with scheduling appointments.
7. Drug Formulary Compliance
Drug formularies are essentially lists of approved drugs drafted by an insurance company. When it comes to workers’ compensation, these lists are used to decide which drugs are most appropriate for an injured worker’s recovery. Formularies are often created by a board of physicians or an established medical organization. Many states have a mandated formulary.
Insurance companies may also create a formulary so they can identify potentially problematic medications. When a claimant visits the pharmacy to fill a prescription, the pharmacy will ensure the medication is covered by the formulary. If it is not, further review may be necessary.
Pharmacy benefit managers work directly with insurance companies to ensure formulary compliance.
8. Better Insights
From the start of a claim, injured employees will more than likely need medication to help them recover and get back to work. When the injured employee visits the pharmacy, a PBM offers adjusters insight into the medications the employee is receiving. If there is any type of problem, the PBM will prevent the medication from being filled until the adjuster issues approval. PBMs also assist insurance companies in navigating the often complex intricacies of workers’ compensation, especially when a worker needs multiple types of medication during the duration of their claim.
Integral to the Workers’ Compensation Process
In short, pharmacy benefits managers are integral to the entire workers’ compensation process. Without PBMs, insurance companies often struggle to provide injured employees with the service they deserve. PBMs provide a seamless experience for both insurance adjusters and injured workers.
