Optum and ESIS Execs Discuss Pharmacy’s Role in Claims Settlement at National Comp

At a digital session produced by the National Comp conference, industry leaders will share how pharmacy and settlement programs can work together to produce better outcomes.
By: | October 30, 2020

Drug spend and claims settlements are two of the most often discussed topics in workers’ comp.

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Controlling drug spend is important not only for keeping claims costs down, but also because payers need to make sure that injured workers aren’t at risk for addiction, especially when opioids are involved.

And who doesn’t love to close a claim? Payers get to take a claim off their books and injured workers hopefully return to work healed from their injury.

Now, industry leaders are looking to combine these two key program goals by using pharmacy programs to set claims up for strong settlements.

In a digital session produced by the National Workers’ Compensation and Disability Conference, industry leaders will describe how tools like clinical reviews, provider outreach, predictive analytics, medication plans, point-of-sale edits and drug testing can help set a claim up for settlement.

The session will look at a case study to demonstrate how pharmacy programs and settlements go hand-in-hand, it will break down how clinical review tools can be used to flag and address high risk claims, it will discuss how these tools can be used to reduce pharmacy costs and it will help attendees gain a better understanding of the Medicare Set Asides (MSA) process.

Presenters include Tron Emptage, chief clinical officer at Optum, Lavonya Chapman, Esq, RN, CMSP, associate general counsel at Optum Settlement Solutions, and Bryan C. Shaughnessy, assistant vice president of workers’ compensation at ESIS.

Pharmacy Clinical Program Tools

The session will open with a case study of a multiple-year, chronic pain workers’ compensation case. In this case, the injured worker had been treated with multiple spinal surgeries and numerous medications to try to address her pain, including opioids and a Benzodiazepine.

These medications could make the claim high risk, especially since in more than 30% of opioid overdoses benzodiazepines are involved. In this case, the worker received prescription after prescription, with some of her 11 medications treating symptoms from the opioids.

After setting the scene with this case study, the panelists will pivot to discuss how tools like drug formularies, drug information delivery and predictive modelling and analytics can help catch claims like this early and provide treatments outside of prescription cascades.

“Clinical reviews, again, use that predictive modelling to identify the risks … to find those patients that benefit from … making change and delivering a better outcome for them and a better economic outcome in the claims in and of itself,” Emptage said.

Preparing for Settlement

Complex and creeping catastrophic claims, like the ones panelists will detail in their case study, represent high workers’ compensation exposures for insurers and are ripe for settlement and the pharmacy tools that PBMs can use to help identify which claims are ready to be settled. During the session, the group will detail how to develop a settlement plan for this type of claim.

One of the questions the panelists recommend that payers ask themselves when dealing with complex or creeping catastrophic claims is if the injured worker has reached maximum medical improvement. If the answer is yes, payers should start looking to settle.

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“As an adjuster, then what I’m going to do is look at my case reserves and make sure my case reserves are sufficient for the exposure that the case presents,” Shaughnessy said.

Some indications that a claim might be ready for settlement include the duration of the claim, the treatments the worker has received and whether or not treatment costs are consistent year-after year.

One thing payers will need to consider when it comes to settling claims is if the injured worker is Medicare eligible and if Medicare reporting or set asides apply — something the panelists will discuss in detail.

“It’s going to be very important to take a look at any responsibility to Medicare and will a Medicare Set Aside allocation apply to what we’re trying to settle,” Shaughnessy said.

CMS thresholds and review, when to use an MSA and strategies to reduce MSA exposure will all be covered during the session. You can register for the session here&


The 2020 National Workers’ Compensation and Disability Conference virtual event occurred on October 21 with six engaging sessions on issues ranging from the industry’s response to COVID-19 to how it can prepare for the impending talent gap.

The conference will continue producing educational content throughout the year through our on-going digital session series and our Comp Talks program, which will deliver on-demand, short form educational content to hit the busy schedules of workers’ comp professionals.

Our next digital session, “Building Off of a Pharmacy Program to Structure a Strong Settlement” will detail how pharmacy program tools, including clinical reviews, provider outreach, predictive analytics, medication plans, point-of-sale edits and drug testing, can act as a springboard to set a claim up for settlement. Tune in on November 5 at 2:00 p.m. ET  to learn how pharmacy programs and settlement programs are working together to achieve workers’ comp excellence.

You can register for this talk, and other sessions in our series, here. Be sure to check back regularly, as new content is being added all the time!

Missed the one-day virtual event? You can watch all the session on-demand here.

Courtney DuChene is a staff writer at Risk & Insurance. She can be reached at [email protected]

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