By Healthesystems
For payers and claims professionals in workers' compensation, pharmacy decisions have always required nuance. But the nature of that decision-making has evolved significantly over the last decade.
In 2012, more than half of workers' compensation claims with prescriptions included an opioid. By 2021, that figure had fallen to just 26%, according to NCCI – reflecting a meaningful shift in prescribing patterns across the industry. Today, claims professionals must now navigate a broader range of medications, prescribing patterns, and pricing considerations.
For workers’ comp stakeholders, pharmacy isn’t just about managing overall cost. Claim duration and injured worker recovery also often hinge on nuanced pharmacy decisions –and those decisions must be carefully managed to ensure the best claims outcomes.
This is where pharmacy workflows come in. A successful workflow does much more than process prescriptions – it orchestrates how decisions are prioritized, informed, and executed within the broader claim context. The most effective workflows speed claim progression and increase efficiencies, all while driving better outcomes for patients. Let’s look at the six essential steps that should be part of every pharmacy workflow.
Step 1: Automate the Routine
Claims professionals face tremendous workloads with ever-increasing challenges, and they need solutions that reduce their burden. This makes claims automation one of the most meaningful levers for improving how pharmacy decisions are managed in workers’ comp. When routine, low‑risk pharmacy transactions are automated, we can reduce cognitive load for claims professionals and ensure that straightforward decisions don’t compete with more complex ones for attention.
In effective pharmacy workflows, automated rules are applied to check for claim validity, state rules, payer policy, formulary alignment, drug risk flags (such as abuse potential or utilization changes), and more. The depth and precision of these rules, and how consistently they are applied, plays a critical role in how reliably low-risk activity can move forward without intervention.
Applying this rule-based automation contributes to a meaningful reduction in manual touchpoints, freeing claims professionals to focus on the smaller subset of decisions that impact claim outcomes.
Why this matters: Automation isn’t just about efficiency – it ensures that high-value time and attention are reserved for the claims where pharmacy decisions are more likely to influence duration, cost, and recovery.
Step 2: Elevate the High-Impact
Not every pharmacy transaction carries the same level of risk. Rather than routing all pharmacy activity equally, effective pharmacy workflows define risk criteria to prioritize higher-impact decisions and scenarios early. Routine transactions move through without interruption, while automated rules flag emerging risk and route those transactions to a priority queue for review and possible escalation.
Examples of pharmacy risk signals/triggering criteria include:
- Utilization pattern changes, such as rapid increases in refill frequency or early refill requests
- Medication complexity, such as the addition of a second CNS depressant or transition from a short-acting to a long-acting opioid
- Dispensing or billing scenarios that require additional review, such as physician-dispensed medications, paper bills, or transactions occurring outside traditional point-of-sale workflows
- An escalation in Morphine Milligram Equivalent (MME) – a value used to compare the potency of an opioid dose relative to morphine
- Opioid use extending beyond the acute phase of injury
Why this matters: Claims professionals are presented with the highest-impact decisions first, ensuring that critical decisions are not delayed or missed within a high-volume workload.
Step 3: Route to the Right Role
As mentioned, effective pharmacy workflows should automate what is routine – while elevating what requires judgment, context, or clinical insight to the right people.
Sophisticated pharmacy management systems use predetermined criteria to add a supervisory or clinical review on top of the claims professional’s prior authorization recommendation and/or route the decision to the right role within the claims team, whether that’s a supervisor or a nurse case manager (NCM).
Scenarios where this routing and escalation might happen include:
- When prescription patterns indicate increasing opioid risk, such as rising MME or early refills, automation flags the claim.
- When prescribing activity signals potential outlier behavior, automation aggregates and flags the pattern.
- When a prior authorization for a high-risk or guidelines-nonadherent medication is approved or recommended, automation identifies the exception.
Why this matters: The right people with the right expertise are given the chance to review claim decisions in real time, ensuring the most appropriate therapy is prescribed.
Step 4: Deliver Context
Meaningful pharmacy decisions are rarely about a single prescription; they require an understanding of how a request fits within the injured worker’s broader drug regimen and overall pharmacy‑related risk. For instance, one opioid may not be cause for concern, but if that opioid increases the patient’s MME to a concerning level, approving it could be a safety risk for the patient.
In an ideal workflow, this context is not spread across multiple systems – it is surfaced directly within the prior authorization and review process, so it is available to claims professionals at the moment a decision is required. Relevant pharmacy insights are embedded alongside the request, enabling reviewers to assess risk and appropriateness without needing to manually piece together information from disparate sources.
Examples of claim-related contextual information include:
- Medication overlaps
- Refill cadence
- Drug cost
- Cumulative exposure (including cumulative MME)
Why this matters: Providing context at the moment a decision is made enables greater consistency, earlier signal recognition, and more confident prioritization across claims.
Step 5: Enable Action
Identifying the right moment to intervene is only part of the equation; claims professionals also need the ability to act without friction. In effective pharmacy workflows, action is not separate from insight – it is embedded into how work is presented and completed.
That means when higher-impact pharmacy activity is elevated, the appropriate next steps are clear, the necessary tools are immediately accessible, and the claims professional can act without leaving the workflow.
Potential actions/interventions that may be taken on a claim include:
- Sending a letter of medical necessity to the prescriber to challenge a formulary-nonadherent medication
- Requesting a complete review of the patient’s medical record and drug regimen
- Referring the patient to beneficial services such as behavioral health, a urine drug screening, or independent medical evaluation
Why this matters: Users can get the information they need and even order interventions directly within their pharmacy workflows, helping to ensure the appropriate services and interventions are applied to the claim without delay.
Step 6: Measure Results
Truly effective pharmacy workflows don’t just end once action is taken; they extend through to understanding how consistently those decisions align with program intent. While automation and intelligent routing ensure the right pharmacy decisions are made by the right role and at the right moment, assessing and measuring claims professional behaviors closes the loop between guidance, action, and performance across claim teams.
Examples of claims actions that can be measured may include:
- Whether prior authorization decisions align with formulary recommendations
- The consistency of decision-making across similar claim scenarios
- The frequency and type of exceptions or overrides
Why this matters: Insights gleaned from claims team decisions/actions inform opportunities for targeted coaching and training, ensuring claims teams are given the guidance they need for optimal performance.
Effective Workflows Are About More Than Efficiency
Effective pharmacy workflows are not only defined by how quickly prescriptions are processed, but by how deliberately decisions are made and how positively they influence the direction of the claim. By automating routine activity, elevating high-impact interventions, and equipping the right roles with meaningful context and actionable pathways, claims organizations can exercise stronger control over pharmacy-related drivers of claim duration and cost.
Ultimately, effective pharmacy workflows enable payers to shift to a more proactive model focused on early identification, right-time intervention, and measurable impact. In a workers’ compensation environment where a small percentage of claims drive a disproportionate share of complexity, this shift can make a meaningful difference not only in operational performance, but in injured worker outcomes.
Learn how Pharmacy Benefit Managers can support more efficient, effective pharmacy workflows here.
