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Killing claimants..

A doctor prescribes massive doses of opioids for a claimant; that prescription is denied; another physician writes the exact same prescription, the claimant gets the drugs, dies, and the insurance company that paid for the drugs is liable.
Only in workers comp.
I’ve received no fewer than eight emails and references to this in the last few days; all express outrage – outrage that any physician would prescribe these drugs, outrage that the second prescription wasn’t rejected, outrage that the doc that wrote the second prescription was the sister of the first prescriber, outrage that the insurance company is somehow deemed liable for the death.
I won’t get into the court’s decision re liability; Roberto Ceniceros has that discussion covered here. That’s dealing with the result. What makes me insane is the simple reality that the claimant got drugs they never should have received.

Because the system – denying inappropriate care through the state-regulated utilization review process – worked. The pharmacy that received the initial script refused to fill it.
Here’s a few more details that add even more concern.
The claimant was prescribed fentanyl patches which were supposed to last two days per patch. Two days after the script was written, there were only four patches left in the box. According to court records, “Subsequent toxicology reports revealed that Fentanyl alone was sufficient to account for death, in even a tolerant user, as Decedent was [sic] certainly was. Decedent died from drug intoxication due to an overdose of Fentanyl prescribed for his work injury.”
This was in addition to “Propoxyphene, which is [sic] synthetic narcotic analgesic, frequently compounded with non-narcotic analgesics; Oxycodone, a narcotic analgesic, often compounded with other ingredients such as non-narcotic analgesics…”
Oh, and the doc who prescribed the drugs that killed the claimant worked in her brother’s practice; was referred the claimant by her brother, who told her to “handle” the situation; knew the UR determination had rejected her brother’s initial prescription; yet wrote the exact same script – for Sonata, Fentanyl, Oxycodone, Fentora, Docusate, and Lyrica.
What does this mean for you?
It is abundantly clear that opioid usage in workers comp is a national disaster. PBMs and payers have to start – or step up – screening for overuse and denying scripts that are not medically necessary. Physicians exhibiting these prescribing patterns have to be very carefully scrutinized. PBMs and payers have to work together to identify claimants at high risk for addiction, assess those claimants, and get them into treatment.
And we need to do this NOW.
Court decision is here.

2 thoughts on “Killing claimants..”

  1. Yet another reason why physician dispensing is of concern. When you state: “Because the system – denying inappropriate care through the state regulated utilization review process – worked. The pharmacy that received the initial script refused to fill it”. I cannot help but ask: Who provides the utilization review when the physician does both, the prescribing AND dispensing?

  2. Joe,
    I am not, in any way exonerating or lessening the culpability of these two physicians. Their actions need to be investigated thoroughly. Do you have an opinion about why the PBM community hasn’t stepped up already? Don’t most, if not all, have an active review process already in place on behalf of their clients?

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Joe Paduda is the principal of Health Strategy Associates




A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.



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