Clinical services at Optum
Over the life of a claim, medication therapy adapts and changes to meet the needs of the injured person. Optum manages both cost and the potential for inappropriate use through our proprietary MedAssess Risk Intelligence System™. Risk IS™ holistically manages pharmacy cost and utilization from the first fill to settlement, providing multiple checks, balances, and safety nets. This empowers more effective medication management at every stage of the claim, by:
- Containing costs
- Reducing the risk of poor health outcomes
- Supporting the health and wellness of the injured person
- Promoting business efficiencies
- Encouraging collaboration
Powerful, pre-dispense controls, claim escalation alerts, intervention tools, and opioid utilization strategies work together to do the right thing for everyone involved.
Powerful pre-dispense controls
Even before an injured worker presents a prescription to the pharmacist, utilization management is in place. Whether first-fill or refill, once an injured person presents a prescription for dispensing, real-time connectivity with nearly all of the nation's pharmacies is enabled, and appropriate utilization review tools are activated. For example:
- Medication plans and formularies are built utilizing evidence-based medicine and approved national and regional medical guidelines. These comprehensive formularies guide prescriptions down one of three paths: approved, declined, or held pending prior authorization. This assures the medication therapy regimen is aligned not only with the injury, but also plan specifications, to ensure the injured worker receives the right medication at the right time, and at the right cost for the payer.
- Drug Utilization Review (DUR) proactively watches for potential therapeutic concerns, including multiple prescribers, multiple pharmacies, refill too soon, drug-drug interactions, cost, therapeutic duplication, morphine equivalent dose, and more.
- Prior authorization triggers if certain variables are present, electronically notifying the pharmacist and the claims professional of the need for review – even if the medication is identified as part of the program.
- Step therapy is promoted by alerting the pharmacist to lower cost, yet therapeutically-equivalent alternatives, encouraging the use of generic and/or lower cost first-line therapy options.
Well-managed claim escalation
As a claim matures, our concurrent utilization review programs alert claims professionals of potential therapeutic concerns, providing the guidance, data, tools, and resources needed to make informed decisions about how best to proceed. Examples of these highly effective program components include:
- Clinical audits
- Clinical escalation alerts
- High-risk profiling
- Multiple prescriber service, and
- Generic conversion
Collaborative intervention tools
Despite everyone’s best efforts, there will always be claims that mature into very complicated situations. Optum offers a number of intervention tools that can control costs and ensure optimal outcomes by encouraging communication and collaborative care, significantly reducing the inappropriate use of medications. A sampling of the tools available include:
- Medication review
- Drug testing and monitoring
- Intervention (peer-to-peer)
- Nurse progress monitoring
- Letter outreach
Enlightened opioid utilization management strategies
While some level of risk is associated with all medication therapy, the use of opioid analgesics presents even greater challenges. We have deliberately designed our clinical products and services to mitigate this risk by:
- Emphasizing prevention from the first fill because it is always more difficult to change behavior or therapy regimens after-the-fact
- Limiting utilization of long-acting opioid analgesics until 90-days post-injury, based on evidence-based medicine and accepted medical guidelines
- Providing actionable data and insight to mitigate misuse and abuse situations
- Using technology to facilitate timely, secure communication and claim management