Yesterday’s post about testing work comp patients for opioids struck several nerves; perhaps the most sensitive involves frustration on the part of payers unhappy about paying for tests prescribed by docs who don’t read the results.
That and the outrageous prices charged – and paid – in some states by some labs/physicians.
In addition to several public commenters, I heard from two medical directors yesterday about docs who order tests and never take action when the results are “inconsistent” with expectations. Over the last few weeks I’ve have had similar conversations with pharmacy directors at two large state funds. Simply put, these folks are happy to promote best practices, but do NOT want to pay for tests that are never read.
What’s a payer to do?
First, watch the coding and reimbursement very carefully; your medical bill review function may be able to help identify inappropriate coding and/or coding that looks to be primarily reimbursement-driven.
Second, direct away from those providers engaged in unacceptable billing practices. Yes, I understand you cannot force claimants to use or not use specific providers in some states. I also know payers can encourage/recommend/channel/suggest/educate claimants about specific providers; Express Scripts had some solid results by educating patients about physician dispensing, and their lessons learned can inform your approach.
Third, make the high billers’ lives difficult by doing everything possible to reduce reimbursement; require medical necessity statements, require evidence that the test was actually done, reduce reimbursement by whatever legal means necessary. I’ve talked to a couple payers who have successfully battled physician dispensers using this tactic; one roundtabled the issue with adjusters who came up with several very creative and effective ways to make life extremely difficult for companies billing for physician-dispensed drugs.
And the adjusters really enjoyed it…
For docs who don’t read the tests they have ordered, an outreach program wherein a test with aberrant findings triggers a case manager contact with the treating physician is in place at several payers. While this – like everything else in workers’ comp – is no panacea, it does alert the treating doc that there’s a problem.
There is also technology available and currently in use that can determine if a document emailed to a recipient is opened.
Worst case, the payer can use this information if the claim goes to litigation, and/or to seek a change in physician, and/or to demonstrate culpability on the part of the physician if the patient has an adverse event.
What does this mean for you?
Drug tests are a tool; used correctly they can be very helpful. But tests that are bought and never used are a waste of money. And using the wrong test is like trying to tighten a bolt with a hammer.