Tuesday , May 22 2018
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Rehab West

Physician Directed Pharmacy Review Program

Excessive and chronic medication use among injured employees can result in escalating direct and indirect costs, rarely providing medical benefit. Recent studies demonstrate pharmacy costs represent 20% of the medical expenses in workers’ compensation. Many of these costs can be minimized or eliminated once identified through RWI’s medical bill review program.

Success is more readily achieved through a peer-to-peer conversation between RWI’s physician and the prescribing physician. Documenting a clear treatment plan to support the use of opioids with reevaluation at regular intervals as outlined in Evidence Based Medical (EBM) guidelines ensures all parties are on board with reductions, tapering and/or cessation of harmful medications. Suggested Criteria For RWI Physician Review:

 Treating physician may not be prescribing medications consistent with EBM guidelines and/or often prescribes opioids

 After 8 weeks of disability employees who have not returned to work and are taking opioids or other controlled substances

 Opioid use started beyond the acute phase of the injury for no apparent reason

 Ongoing use with no documentation of functional benefit (which can result in greater dysfunction)

 Drug use possibly preventing employee from returning to work

 Increased risk may exist for additional work related injuries to employee or coworkers

 Potential diversion of medications (financial/economic gain can limit motivation to return to work)

 Excessive amounts of daily opioid use (that may result in accidental death)

 Future Medical Award cases in which medication costs are excessive (provide copy of Award with referral)

 Medications being prescribed by multiple physicians

 Employee often misplaces medication necessitating unscheduled refills and/or ER visits

 Employee urinalysis negative for prescribed drugs

 Employee refuses urinalysis

 Medical food use

 Topical compound use


Review Fees: Physician Fee – $250. per hour billed in .25 increments Provision of reports, faxes, emails at $95. per hour billed in .1 increments To refer a case please provide current medical reports, bills, and specific request for the review to RWI via fax 760.796.7564 or via our web site, workers compensation.

Also see our return-to-work program.


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