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Three key elements critical to improving outcomes for managing ancillary services in workers’ compensation

by | Aug 01, 2019

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With so many factors affecting the outcome of an injured claimant’s case, it’s critical to have a holistic, comprehensive picture of the claimant’s medication history to achieve optimal results. Incorporating the pharmacy spectrum into ancillary management allows a real-world view into what the entire patient care trajectory should look like. Considering medication data is vital when prescribing additional therapies.

For example, recommending durable medical equipment (DME) or physical medicine therapy for a claimant taking opioids or having comorbid conditions may require additional clinical considerations, as these therapies could make matters worse. Having access to the claimant’s medical record is crucial for making strategic decisions to steer treatment down one path or another.

Only PBMs can offer a complete medication picture
Claimant medication data collected by a pharmacy benefit manager (PBM) offers an all-inclusive, patient-centric view that facilitates clinical triage for the best therapeutic action to improve outcomes for the injured claimant and the payer/employer.

A robust technology platform must undergird pharmacy/ancillary care services
An enhanced claimant picture requires a robust technology platform that integrates pharmacy and ancillary services at the point of entry. The technology that powers the Optum Workers’ Comp and Auto No-fault (OWCA) PBM and ancillary care solutions — VitalPoint® portal — provides payers/employers with easy access to pharmacy and ancillary information.

VitalPoint provides real-time visibility into data from the common patient record that exists within the Optum subsidiary of United Health Group, which captures each of the different products/services leveraging the same eligibility file.

An integrated platform delivers better data, insight and predictive tools
This unique patient profile provided by VitalPoint offers a holistic look at all services rendered for the claimant without having to jump from one system to another. The integration of pharmacy and ancillary data fosters actionable insight and better predictive tools to help OWCA clinicians and clients make real-time decisions on appropriate next steps based on the clinical needs and objective. Plus, timely decision-making can reduce costs by preempting issues that escalate costs before they get too far too far down the path.

Visibility to risk score and reporting for the overall health of the business
A complete view into the claimant’s history allows payers/employers to understand how the risk score is influenced by the different services the claimant receives and how these services impact the claimant’s ability to return to work.

VitalPoint data visibility and reporting, illustrated with Tableau® software, lets payers/employers assess the health of their book of business. They can see retrospective bills without having to wait for bill review. It’s a strategic look at what’s happening in real time — allowing payers/employers to identify ways to improve their programs in collaboration with OWCA.

Systems built to promote in-network penetration and identify fraud, waste and abuse
All of the OWCA pharmacy and ancillary programs have retrospective components built in to redirect out-of-network orders into network with the goal of high in-network penetration. In-network processing allows recurring orders to be identified and directed, prospectively, to the highest quality, most effective formulary suppliers with the best cost structure who can also validate the ongoing need for the products/services.

Funneling to formulary suppliers not only can achieve reduced unit costs, but validating ongoing needs is critical to address the fraud, waste and abuse that creates unnecessary costs.

Leveraging integration with suppliers for supply chain management
Similar to the successful pharmacy model, OWCA is integrated with vetted ancillary suppliers who meet stringent requirements. These suppliers are more efficient, which translates into better turnaround times and better cost structures — providing a better experience for payers/employers and injured claimants. 

This supplier integration allows OWCA to automate orders for simple things like canes and walkers, freeing time and energy for services that require a more hands-on approach. Services like home health, prosthetics and hearing-aid programs are more expensive and it’s important for the injured claimant to have a personalized one-on-one experience.

Triple threat
The three components to successful ancillary management — a holistic patient view, including pharmacy; robust technology; and integrating with suppliers — combine to paint a complete picture of the claimant that’s critical for effective decision-making. OWCA offers all three elements which drive better outcomes for payers/employers and injured claimants.

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