Background of Intervention

A 62-year old male sustained a work-related injury less than one year ago. While the body part was not documented, the nature of injury was listed as multiple physical injuries. A retrospective clinical audit performed by a clinical pharmacist identified that a medication, used for the treatment of enlarged prostate, was authorized ongoing by a claims professional. This medication was authorized as the client elected not to use one of Progressive Medical’s Medication Plans. After reviewing the prescription profile, three other medications were identified as potentially unrelated - one medication was used for blood pressure, one for high cholesterol, and one for blood clots. Thus, it was determined that this claimant was authorized to receive four medications ongoing which were potentially unrelated to a typical work-related injury and likely related to a pre-existing condition of a 62-year old male.

Intervention

The clinical pharmacist notified the claims professional that a medication used for enlarged prostate was authorized under the claim. In corresponding with the claims professional, it was determined that the medication for enlarged prostate was to be denied as unrelated to the injury. Additionally, the two medications used for high blood pressure and high cholesterol were subsequently denied as unrelated to the injury. Of the four medications, the only medication allowed was for the blood clots as the claims professional indicated that the claimant was treated post surgery for blood clots.

Results

Based on the current cost of medications, our proactive retrospective clinical review performed by our pharmacist saved the client a minimum of $1,500/year.