Prescription medications make up about 7% of the costs of a workers’ compensation claim in the United States.1 Most of these prescriptions are filled without issue and follow all the appropriate pricing and dispensing rules. Mixed in there, however, might be instances when:
- A pharmacy dispensed a high-priced medication NDC when lower-cost NDC options were available.
- A physician dispensed Lidocaine 4% patches at a much higher volume than local peers.
- A patient filled multiple prescriptions from multiple doctors at multiple pharmacies.
- A pharmacy re-submits denied bills after altering information (e.g., prescriber)
While these cases may be infrequent, they could be cases of medication fraud, waste, or abuse (FWA) and those could lead to higher costs, misuse, and even legal prosecution.
In their latest WorkCompWire Leaders’ Speak article, MyMatrixx by Evernorth experts, Brandie Traylor, Vice President of Product Management, and Cliff Belliveau, Chief Innovation Officer, discuss the “bad actors” that are hiding withing workers’ comp claims and the clinical and financial benefit of a strong FWA program to:
- Look for FWA activities at the pharmacy, provider, and injured worker levels
- Use data to identify and analyze FWA trends and activities
- Take steps to investigate and then correct FWA
Without an FWA program, payers may never know what is happening within their claims. If they can’t see it, they can’t fix it.
1. https://www.ncci.com/SecureDocuments/AES_Content/Medical_Dilemma_Rx.html