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.
Continue reading the article in full at the Healthesystems blog.
