Adjuster X

An Rx Odyssey

By: | May 1, 2014

This column is based on the experiences of a group of long-time claims adjusters. The situations they describe are real, but the names and key details are kept confidential. Michelle Kerr is the editor of this column and can be reached at [email protected]

Juliana, 44, was a deli clerk at the time she suffered a herniated lumbar disc. Several back operations failed. Permanent total disability was approved. When I got the claim, it was 10 years old. The numbers were stunning: $84,000 a year on medical — most of that on prescriptions. Juliana’s drug review was jaw dropping: Oxycontin, Perocet, Prozac, Ambien … plus Amitza, Lyrica and Tigan for other symptoms.

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Juliana wouldn’t take the case manager’s calls, and she failed to keep her scheduled independent medical exam. Juliana finally showed up for her IME three months later.

The examiner recommended in-patient detoxification and a psych evaluation. She continued to evade the case manager, and blew off her psych evaluation as well.

Through all of this, I got calls from Juliana. First she lost her handbag and needed immediate authorization to replace Oxycontin and Percocet. I couldn’t disallow her medication so I reluctantly agreed.

Then she wanted an early refill because the weather was worsening her pain. I refused to approve it without a doctor’s note.

After I limited her prescriptions to 30-day supplies, she called me when she needed them renewed. I told her point-blank that she was non-compliant with requests for case management and the psych exam. She became hostile and hung up.

An investigator reported that Juliana wasn’t home. A neighbor said she frequently drove to her home in Florida to convalesce — surprising for someone with intractable back and lower extremity pain.

I called our pharmacy benefit provider to request prior authorization before dispensing. But I found out she had called two weeks before, from Florida, claiming her medication bag fell into a pool and became contaminated by chlorine water. They sent her a 30-day supply.

Further surveillance found Juliana driving, shopping, and getting around without any apparent difficulty. She even loaded groceries into the trunk.

Shortly thereafter, Juliana’s attorney requested a hearing to ensure she was receiving proper medical care. The hearing was scheduled two months out. In the meantime, I deauthorized her existing primary care doctor and recommended alternate providers.

At the hearing, the judge was less than pleased with Juliana’s lack of compliance. She admonished the attorney that the carrier had the right to direct care and exams. She also supported a detox program.

Despite deauthorization, Juliana continued seeing her regular doctor. She missed her follow-up court hearing, claiming she was ill.

She returned to Florida, so we hired a local investigator. On the last day of the surveillance, he observed Juliana in a parking lot, passing a plastic bag to an unidentified man. Of course I suspected Juliana was selling her surplus medication.

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I requested a new hearing. The judge was given surveillance reports and informed about Juliana’s attempts at early medication refills or other end-around runs. The judge was firm in her ruling: Juliana would need to be compliant, use only authorized providers and attend a detox program — or suffer the consequences.

Juliana agreed to enter detox. But 10 days later, she signed herself out.

We filed for a new hearing. As we hoped, the judge suspended all benefits until Juliana agreed to be compliant and re-enter detox. We never heard from Juliana again. Getting there took nearly two years, but in the end, it was worth it.

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The R&I Editorial Team can be reached at [email protected]