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Thread Title: Medications sent to U.R.?
Created On Monday September 22, 2008 8:34 AM

postscript2
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Monday September 22, 2008 8:34 AM

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I know that medications are a large component of a treatment plan, esp. "pain medications." In the summer of 2007, many claims administrators were running scared due to the new audit penalties and decided to send "every" request for treatment through U.R. Now I am hearing of a few circumstances in which pain med's are being sent to U.R. for review.

This does not seem appropriate to me. While one person may be able to handle pain with OTC meds, another may not--and in the interim (sp?), if a person is used to taking prescriptions drugs that they are dependent upon, the delay could have a really bad effect upon an I/W.

Anyone else heard of this? Is this a necessary, mandated action, new wave of the future???

What's next, sending a request for a PTP to U.R.? -Or retro review for an ER visit???

Geez!

LCS

Michaelb
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Monday September 22, 2008 9:29 AM

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Last week I did a QME based on an UR denial of NEXIUM.
The patient had taken CELEBREX which irritated his stomach.
The PTP did not renew the prescription but told the patient verbally to try over the counter Ibuprofen.
The irritation continued and the PTP ordered NEXIUM to counter the irritation.
UR noted that there was not a current prescription for anti-inflammatories and denied the NEXIUM.
UR denied both the need for and strength recommended.

postscript2
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Monday September 22, 2008 9:55 AM

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In that case, which is scary, the anti-inflammatory could have caused irreparable stomach damage, even in the event that the prescription for Celebrex was DC'd, right???

I'd be willing to bet that the U.R. charges for "review" cost more than the rx for the stomach medication. What ever happened to "cure AND relieve?"

I see "compensable consequence" written all over this scenario! Does not a PQME resolve this dispute? I wonder what would happen if there was an "Award" for FMC and the 4061/4062 dance was overwith...

But I digress. Sigh...

LCS

gaiassoul1@yahoo.com
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Monday September 22, 2008 3:03 PM

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medications are defined as medical treatment in the LC, if you don't send medications to UR they must all then be authorized.

This is not a wave of the future and has been ongoing in, correctly in many companies since UR started.

The less adept at adjusting claims of course don't do much right and that included the lack of training as to the definitions of medical treatment and what UR applied to. Then per Sandhagen then have difficulty defeating a pharmacy lien.

A Claims adjuster cannot modify, delay or deny, so yes medications go to UR.

Further unless something is specifically excluded from the UR plan or authorized....it all goes to UR.

The correct applicant response to a UR denial of treatment if they want the treatment is to object and proceed to the medical-legal process.

postscript2
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Monday September 22, 2008 4:06 PM

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Although I tend to agree in part, it is still my opinion that the potential delay in providing at a minimum medications to cure and relieve is nonsense. The question I'm posing now, is that if the med-legal process has already been completed and medications are specifically recommended-then what is the purpose of running them through U.R.?

It's seems to be a vicious cycle to go through the med-legal channels only to have U.R. overturn what an AME or PQME says.

I wonder who would be held accountable for not authorizing appropriate medications for an injury while the U.R. process is going on. Thank God for providers of service whom are willing to step up to the plate and provide the necessary medications during said process. This is exactly why there are compensable consequences - and a driving cost factor in claims,, period.

It's not just the C/A's whom are less "adept" to adjusting, but equally to blame are the "inept," whom do nothing at all. I understand the rationalle between the "all or nothing" authorization process, I just wholly disagree. This is not what I have gleaned from the U.R. Regs and seminar's I've attended.

AND, U.R. is definately a delay--but I guess the C/A can pin it on the out of state nurses whom under the direction of an MD of any specialty or not--make a decision with little or no facts about a case. In the meantime, the I/W suffers. At a bare minimum, IMHO, medications should be authorized at least until the U.R. opinion comes back and even better the med-legal opinion.

Oh well, another day in paradise... Common sense just flew out the window, once again.

LCS

Edited: Monday September 22, 2008 at 6:37 PM by postscript2

TOBDNCNG@aol.com
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Saturday October 04, 2008 1:25 PM

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Sorry to be responding so late, just catching up with my e's.

I have posted this before for those who are having trouble getting meds approved. They say they accept everyone/anyone, WC or regular accidents.

Buena Vista Pharmacy
23679 Calabasas Road, #800
Calabasas, CA 91302
Comp@buenavistarx.com
1 (800) 583-0058

Good luck... Someone has to help the injured employee.

Glowing,

Marygrace~

dlupinsky1
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Friday October 17, 2008 9:51 AM

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I think that it is interesting that you state "Or retro review for an ER visit". In line with the topic of medications, it is not uncommon for patients with drug seeking behavior to go to the ER to try and get more medications. So we as a UR company do see retro reviews of ER visits that are not appropriate.

The finger seems to get pointed at UR companies as if we are the ones that are not looking out for the patient. How about the PTP's that are prescribing Actiq for patients with a soft tissue injury? Or the adjusters that don't send those types of treatment requests to UR? Have you guys ever heard of iatrogenic disease? If not, I recommend that you Google it. More care is not necessarily better care. I work at a UR company and I can without a doubt attest to the fact that everyone here from the medical director down is a patient advocate and is not just looking to deny care.

I can't speak for all UR companies, but I don't think that UR in general is the culprit.

rosellavera
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Friday October 17, 2008 10:15 AM

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I see more and more PTPs dispensing medication from their office without first attempting to get authorization. For example, yesterday I reviewed a bill from the PTP for medication he dispensed. He Rx 100 vicodin on 9/19/08, another 100 vicodin on 9/20/08 as well as two bottles of Norco on that same date. I always thought there was a limit on the amount of narcotics that a doctor could prescribe monthly. Sadly, I know of an injured worker in Oxnard who makes ends meet by reselling her medication on the black market. UR is not such a bad idea.

docwats
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Wednesday October 22, 2008 2:00 PM

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I've read over the posts responding to you, have the following observations:

Using Nexium to counteract Celebrex is quite common, but in my opinion should not be common. Nexium won't prevent ulcers that might be caused by Celebrex or OTC ibuprofen, etc. Few medications for pain provide significant "relief" and almost never do they provide "cure", and there are significant risks such as these and with narcotics and "muscle relaxers".

Not all medication situations should be seen as having the same need for UR, in my opinion. Skin infections needing acute antibiotic treatment is not equivalent to severe unremitting pain from a lifting injury six months ago, is different than the same pain since a fall yesterday.

I've had low-dose antidepressant (Elavil) denied despite ACOEM lukewarm approval of it for chronic back pain; the stuff is cheap, less than UR could ever be, not harmful if prescribed properly.

I think we would be better off if all "muscle relaxant" prescriptions were denied, past a few days.

Maybe if the CA providers get a decent reimbursement on Fee Schedule, they would see less need to dispense meds to make ends meet. No, probably not. Maybe that could be part of the deal: increase reimbursement for E/M, hold the line on meds. And 100 Vicodin at an initial visit? ACOEM has its flaws, but I have found its guidance on analgesics quite sound. I prescribe less, seem to get better results.

I think duplinsky1 is correct in suggesting that UR may prevent harmful unnecessary treatment. I'd like to see a study into how significant that is.

Jpod
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Thursday October 23, 2008 8:49 AM

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Docwats, isn't that what led to ACOEM? The observation that treatment plans themselves can actually interferre with healing?

I believe it was the Israeli army that did most of the research that led to ACOEM, but I have this information second hand and do not know much more, or even if what I was told was true. It was in a class on ACOEM shortly after its adoption.

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