As pharmacists and analysts, we bring an integrated, clinical focus to our Workers’ Compensation consulting services. RJ Health Systems reviews patient records and drug therapy to control spending and improve clinical outcomes. This includes evaluating compensability, appropriate utilization, drug-drug interaction, therapeutic duplication, and generic or less costly alternatives. We consider the long-term health ramifications for each claimant and seek to prevent unnecessary costly medical interventions.
Our clinical staff understands the challenge of managing the increasing costs of drugs while ensuring that the injured worker receives the most appropriate therapy. RJ Health Systems provides a customized analysis based on clients’ objectives, reviewing individual cases, nature of injury, medications and other variables.
Services
- Concomitant and Retrospective Drug Utilization Review
- Pharmaceutical Management
- Compliance Initiative Programs
- Data Analysis
Often, after a worker becomes injured and is prescribed medication, years can pass without a drug utilization review determining whether continued use of the medication is appropriate. There may be potentially negative implications for the claimant, such as cardiovascular problems, with sustained use of medication that can lead to future complications if unchecked.
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RJ Health Systems can assist in ensuring that claimants receive optimum appropriate pharmaceutical care. Our clinical staff develops criteria, evaluates the appropriateness of the medication based on the injured worker's condition, and identifies potential issues, such as drug-drug interactions, high dosing, and therapeutic duplication. If warranted, RJ Health Systems contacts providers directly to discuss the claimant's medical history and possible modifications.
Services include:
- Criteria Development, Evaluation, and Monitoring
- Disease State/Drug Class Appropriateness
- Generic Substitution Opportunities
- Identify Potential Drug-Drug Interactions
- Individual Injured Worker Drug Profile Analysis
- Customized Client Reporting
Communication Vehicles for All Participants
- Injured Worker
- Prescribing Physician(s)
- Dispensing Pharmacy(s)
- Case Manager
- Claims Adjuster
We help clients gain control of the cost of Workers' Compensation cases through active pharmaceutical management. Using pharmaceutical data, we perform a clinical and financial analysis of an injured worker or set of injured workers. We analyze the spending on generic and brand name drugs and their therapeutic classes, and recommend more effective policies and procedures.
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Formulary Management
From formulary development/management and step therapy edits to prior approval management and data analysis reporting, RJ Health Systems can help develop the programs and reporting necessary to effectively manage pharmaceutical care.
- Formulary Development - customized for client and industry-specific
- Policy and Procedure - client-specific for Prior Authorization/Medical Review
- Step Therapy Protocols - for specific drug classes
Pharmacy Services and Customer Service Department
- Acting Director of Pharmacy assuming all responsibilities on behalf of client
- Dedicated Customer Service representatives, including Registered Pharmacists and Certified Pharmacy Technicians
Financial Reporting
- Claims analysis using detailed reports with standard and customized reporting packages
- Client-specific ad hoc reporting
- Trend reporting
Non-Clinical Services
- Represent client at industry gatherings
- Participate in strategic planning initiatives at client's senior management level
- Manage relationship with PBM
- Attend meetings (on or off-site) at the request of the client
- Other areas as requested by client or client's designee
Keeping informed of changes in pharmaceutical utilization, product info and safety concerns is of vital importance to Pharmacy Benefit Managers, claims adjusters and others involved with the management of the claimant. Toward this end, RJ Health Systems regularly publishes newsletters and advisories with information about drugs and new drug alerts.
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We also contact providers directly when we identify areas of concern, such as the potential harm from long-term use of a particular medication, late/early refills, suspected diversion, and drug-drug interactions. We generate a report for each claimant, which we can send to the provider’s office for review and comment.
Services include:
- Newsletter updates inclusive of FDA alerts, Drug Recall, Safety Issues
- Provider education
- Case Manager/Claims Adjuster on-site and distance training
RJ Health Systems reviews patient data and identifies opportunities to increase positive outcomes for claimants while improving cost effectiveness. Our clinicians evaluate each claimant’s drug history to identify potential drug interactions, high dosages, duplicate therapies, and possible signs of drug misuse.
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Sample offerings include:
- Quarterly Prescription Performance Report
- Quarterly Impact Report
- Quarterly 13 Month Rolling Scorecard
- Quarterly Variance Report
- Quarterly Subclass Summary
- Drug Spend – Drugs of Interest
- Therapeutic Class Specific Spend of Questionable Compensability
- Drug Specific Spend of Questionable Compensability
- Client Spend vs. National Benchmark by Therapeutic Class
- Additional Reports Generated, Analyzed, and Findings Reported if Warranted
Retrospective Drug Utilization Review
Claimant Specific Reports
- Retrospective Drug Utilization Review
- Individual Impact Report
Ad Hoc Reports
- Per Client Specifications (e.g., Drug Spend by Adjuster Activity)
Clinical Reports/Communication Pieces
- Duplicate Therapy
- Drug-Drug Interaction
- High Dose Aceteminophen
- Multiple Benzodiazepines
- Multiple Short-Acting Narcotics
- Multiple Long-Acting Narcotics
- Long-Term Use of Meperidine
- Use of Multiple Prescribers
- Use of Multiple Pharmacies
- Brand/Generic Conversion Opportunities
