MedAssess™—Unique, clinical solution impacts utilization, promotes intervention, and provides care throughout the claim lifecycle
MedAssess is PMSI’s unique clinical approach to assess and manage appropriateness and utilization throughout the claim lifecycle through high-quality services and programs that improve injured worker outcomes. Through the use of our MedAssess Risk Intelligence System™, PMSI can identify catalysts for growing utilization costs and give clients stronger control over medicine and medical needs at both the population and injured worker levels. The Risk IS™ tool is built on PMSI’s robust pharmacy and medical database of over 10 million transactions and PMSI many years of expertise in managing and identifying risk.
MedAssess programs are designed to clinically monitor and assess proper utilization and appropriateness of therapy based on the progression point of the claim:
- Pre-Dispense Controls
- Claims Escalation
- Intensive Intervention
Pre-Dispense Controls begin at the point-of-sale, before medication is dispensed to stop potential issues before they start. For pharmacy transactions, medication use is controlled through programs such as prospective Drug Utilization Reviews (DUR), Formulary, Prior Authorization and Step Therapy. For durable medical equipment (DME) and home health care transactions, equipment and services are controlled through application of Formulary, Product Substitution criteria and Clinical Policy Guidelines. These programs are the first line of defense to help promote use of appropriate medications and services while still providing access to the items an injured worker needs for recovery and return to work.
Claims that age past three months generally involve chronic injuries with higher utilization, requiring more extensive clinical oversight. In the Claims Escalation stage, a risk-profiling methodology is applied to uncover situations that might go unnoticed at the individual prescriber or pharmacy level. Using our MedAssess Risk IS analytical engine to screen the injured worker population, the PMSI identifies high-risk, high-cost injured workers and reaches out to prescribers and/or claims professionals to improve care. Services within this stage include: Clinical Escalation Alert, High-Risk Profiling, Multiple Prescriber, and Generic Conversion.
As a claim ages, the workers’ compensation pharmacy and medical spend typically increases. Much of this increase is associated with the inappropriate use of medications, products, and services in these chronic and complex populations. Intensive Intervention programs were designed to provide a more comprehensive approach that goes beyond risk assessment and individual interventions to creation of comprehensive action plans and follow up. The result is better control over injured workers' therapeutic outcomes and cost of care. Intensive Intervention programs include Medication Review (with optional Peer-to-Peer Outreach) and Drug Testing and Monitoring.
In order to meet several unique industry challenges, PMSI has also created comprehensive solutions that integrate the capabilities of specific MedAssess services to address complex issues such as Pain Management, Fraud, Waste and Abuse, Opioid Management and Catastrophic Care Support.