Neck and back injuries led to multiple surgeries and a difficult-to-maintain pharmacy regimen for the patient, David. The payer wanted to set lifetime reserves on a complex and expensive case. ANS identified opportunities to reduce “red-flag” medications, then worked with his treating provider and plaintiff attorney to make modifications that ultimately led to a clinically appropriate regimen which David could realistically follow.
While working at a health care facility in 1999, David sustained neck and back injuries, resulting in many surgeries over years of treatment—and a pharmacy regimen including three experimental topical compounds, muscle relaxants, and opioids. His additional diagnoses of Complex Regional Pain Syndrome (CRPS), anxiety, insomnia, and headaches only added to the complexity of treatments and dramatically impacted his quality of life.
To best help the payer set appropriate lifetime reserves for David, ANS conducted our free, No Fee Assurance (NFA) review to understand whether the case should be referred for medical cost projection, or pharmacy intervention. The NFA analysis pointed to pharmacy intervention, given that David’s pharmacy regimen included three costly experimental topical compounds, multiple brand name medications, and two muscle relaxants—in conjunction with elevated opioid use. All of these factors added up to numerous clinical red flags and an astounding $30,000 per year in pharmacy treatment.
The claim’s jurisdiction required ANS to obtain consent from David’s plaintiff attorney before reaching out to the treating prescriber. What followed was a successful face-to-face intervention that included our clinical nurse consultant, the prescriber, David, and his attorney. From there, we secured discontinuation of the costly experimental topical compounds and David was weaned from the muscle relaxants. It was a gradual process but a rewarding one. After the full-year PharmCompliance program, ANS was able to develop a medical cost projection, allowing the carrier to accurately reserve based on the new, less costly, treatment regimen.
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