White Paper
The Crystal Ball of Claim Complexity: How Early Pharmacy Activity Helps Reveal Risk
White Paper Summary
What if you had a crystal ball that could predict the future? In workers’ compensation, complex claims rarely become complex overnight; the challenge is recognizing the signs so we can intervene. As a workers’ compensation pharmacy benefit manager, our “crystal ball” is pharmacy activity, which serves as one measurable indicator of future claim complexity.
Because pharmacy utilization often begins immediately after injury, it is one of the earliest, most consistent data streams available to flag elevated risk – especially when it reinforces other indicators such as injury type, comorbidities, psychosocial concerns, and more. While no single prescription necessarily predicts a problematic claim, multiple pharmacy signals appearing together can provide a warning that the claim may be headed toward greater cost, duration, and clinical complexity. There are early risk signals hiding in medications and utilization, patient behavior, prescriber behavior, and channels used to obtain medications.
By understanding these signals, we can approach complex claims differently – moving from a reactive approach to a more proactive strategy that may prevent routine, manageable claims from becoming complex in the first place.
For more content like this from Healthesystems visit their RxInformer clinical journal website.


