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Physician Dispensing in Work Comp. Impact of the practice on overall costs and exposure Tips on how to manage it. Pharmacy drives 10-20% of your unit cost as a percent of total medical. What percent of your total exposure relates to claims with prescription meds and IWs suffering from pain?.
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Physician Dispensing in Work Comp • Impact of the practice on overall costs and exposure • Tips on how to manage it
Pharmacy drives 10-20% of your unit cost as a percent of total medical. What percent of your total exposure relates to claims with prescription meds and IWs suffering from pain? Source: 2011 NCCI Issues Report
Physician Dispensing Price Difference: Tramadol • * Percent of mark-up measured against original manufacturers’ AWP.
What the studies say: Impact of Physician Dispensing on Total Claim Costs
Questions for the Audience • Where do we see “third party billing?” • Retail, Physician Dispensing, Everywhere! • Stone River (retail and physicians), Prescription Partners
Questions for the Audience • Where do we see “third party • Partners • What is the legal status of the third party biller? • Assignee • What are the obligations of an assignee? • Identical to the underlying provider
Questions for the Audience • Where do we see “third party • eywhertail and p • What are the obligations of an assignee? • Identical to the underlying provider
Assignees are ALREADY OBLIGATED! • PBM Contracts with underlying pharmacies • PPO Contracts with underlying prescribers • The Facts
Assignees are ALREADY OBLIGATED! • PBM Contracts with underlying pharmacies • PPO Contracts with underlying prescribers • Impact of contracts with assignees • Grant them rights and frees them from obligations • Disables Prospective Mgt/ Enables more retro • PBM re-sells transaction at a spread • Expedient? • Right thing to do? • The Facts
Apply underlying PPO discount • Can I? • Everywhere? • Yes you can! • Deny subsequent transactions based on PPO contractual obligations • Can I? • Everywhere? • PPO - Utilization Mgt or specific prohibition • Contractually yes, but leverage is the issue • Requires notice • Re • What you can do
Question for the Audience • What presents more risk in terms of your cost drivers? • Unit price? • Utilization? • The unknown?
Identify providers who dispense meds in office • Leverage bill review • Manage the data • Maximize provider selection tools • Include a physician dispensing indicator • Layer the order based on criteria • Preclude panel populating • Educate your PPO providers • Re You can make the unknown more known!
