MedAssess™—Unique three-level solution impacts utilization, promotes intervention, and provides care

MedAssess is a unique clinical approach to assess and manage appropriateness and utilization throughout the claim lifecycle through high-quality services and programs that reduce costs and improve outcomes. The program can uncover the reasons for growing utilization cost and give you stronger control over your injured workers' medicine and medical needs.

MedAssess integrates three levels of care—Utilization Control, Targeted Intervention, and Care Management programs to coordinate throughout the injury lifecycle and improve the quality of care for injured workers, promote rapid return to work, and reduce costs. Learn more about how MedAssess can help you achieve outcomes such as a 64% savings.

First level of care: for acute and chronic injuries
Proactively manages access to medications through both a Prospective Drug Utilization Review (DUR) and a workers’ compensation-specific formulary. For catastrophically injured workers, medical services and equipment orders are reviewed by a clinical nurse for appropriateness and cost effectiveness at the point of service. As a claim ages and grows closer to settlement, usage requirements can be managed through our Drug VALUE Review to determine pharmacy allocations appropriately.

Second level of care: for chronic cases
Using population-based screening, MedAssess identifies high-risk, high-cost injured workers and reaches out to prescribers and/or claims professionals to improve care. The program applies a risk-profiling methodology to uncover situations that might go unnoticed at the individual prescriber or pharmacy level.

Services within this level of care include High-Risk Profiling (also known as Arkos Risk Management™ system), which addresses high-risk claims, and the Multiple Prescriber service, which alerts prescribers and claims professionals about their injured workers who are receiving pain medications from multiple providers. In addition, the Generic Conversion service reaches out to physicians and injured workers regarding switching from brand-name to lower-cost generic medications.

Third level of care: for chronic and complex claimants
A more comprehensive approach that goes beyond risk assessment and intervention—to action plans and follow up in order to gain better control over therapeutic outcomes and cost of care. As a claim ages, the workers’ compensation medical spend increases and much of this spend is associated with the inappropriate use of medications, products and services in this high-risk population.

PMSI’s Care Management program is designed to assist with the care of these individuals and includes services such as Medication Review that provides a comprehensive assessment of the injured worker’s pharmacy and medical record and yields recommendations and an action plan tailored to the injured workers’ needs. If requested, PMSI’s optional Peer-to-Peer Outreach service will engage the identified prescriber to facilitate change to more appropriate therapy. The Drug Testing and Monitoring service monitors injured workers taking high-risk medications to confirm adherence to the prescribed plan of care.

In order to meet several unique industry challenges, PMSI has also created holistic programs that incorporate services from each MedAssess level of care. These specialty programs address issues such as Pain Management, Fraud and Abuse Prevention and Catastrophic Care Support.