Employers, state funds, and insurers are focusing more and more on closing old claims; the most successful ones are partnering with their Pharmacy Benefit Managers.
The logic is clear – the older and more costly the claim, the greater the percentage of spend is for drugs (except for those cat claims needing long-term home health/facility care).
And, the higher the reserves, the greater the percentage of those reserves is for drugs (except for those cat claims needing long-term home health/facility care).
Both graphs from NCCI; Medical Services by Size of Claim—2011 Update.
While some very large payers (e.g. Ohio BWC, Washington L&I, State Fund of California and Sedgwick) have strong clinical pharmacy capabilities, most payers don’t.
If you are looking to reduce your claims inventory, partnering with a PBM with:
- real expertise in analyzing legacy claim information,
- very strong clinical capabilities, and
- a demonstrated ability to help manage legacy claims is mandatory.
What does this mean for you?
Find out if your PBM has these capabilities – and ask how they can help you. If you aren’t impressed, find another PBM.