Administering automobile no-fault claims comes with competing priorities and myriad tasks. Partnering with a proven, highly qualified durable medical equipment, prosthetics, orthotics and medical supplies (DMEPOS), pharmacy and ancillary service provider that acts as a pharmacy benefit manager (PBM) can bring multiple benefits to your insurance company. However, it is important to assess whether your PBM is delivering value to the partnership.
One area to examine when considering the question of value pertains to prior authorization. A number of PBMs tend to use a formulary when it comes to pharmacy services. If your PBM uses a formulary, it could mean that your insurance company is paying for medication that is not related to a claimant’s injuries.
For example, a claimant who was injured in an automobile accident but also had pre-existing issues requiring mild pain management may have been prescribed a number of medications, including Motrin. Under a formulary, the PBM would authorize the Motrin prescription because it was issued by a medical provider treating the claimant’s auto injuries, even though the Motrin was for a pre-existing issue. It is critical that your PBM has processes in place to ensure the auto relatedness of all physician prescribed services.
In this case, a PBM that uses pre-authorizations rather than a formulary would deliver a higher value. When a PBM utilizes pre-authorization, they review each and every prescription medication for injury relatedness before approving the prescription. Going back to the Motrin example, pre-authorization would flag the fact that the claimant was already receiving a Motrin prescription from an unrelated injury that happened prior to their auto accident. Because it is not injury related, the PBM would not approve payment for the Motrin, which then prevents the insurance company from paying for a prescription that is not related to the claim.
In addition, a PBM delivering value would also provide your company access to a network of pharmacy providers offering negotiated rates. This ensures your claimants receive convenient and quality medical care for injuries stemming from their auto accidents. It also means cost containment for your company since the providers must agree to discounted fee schedules before joining the PBM’s network.
Northwood is a highly qualified PBM with over 30 years of experience caring for claimants. In addition to delivering value to its claimants in the ways listed above, Northwood offers coordination of benefits for claimants without full coverage. Because Northwood is one of the only providers to offer coordination of benefits, it brings immense value to insurance companies in its role as a PBM.
To learn more about the value Northwood can bring to your insurance company as a PBM, please schedule a meeting with Rosanne Brugnoni by calling 586-755-3830 ext. 3771.
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