Lock-In Services
Industry Challenge
When recipients abuse their pharmacy benefits to obtain excessive quantities of prescribed drugs, Medicaid agencies can lose large sums of money. Excessive quantities can be obtained through a variety of methods, including multiple visits to pharmacies, multiple visits to physicians, and early refills.
Solution
HID’s Lock-In solution, RxCorCare™, helps Medicaid agencies address situations where patients are abusing a pharmacy benefit in a manner that amounts to fraud, overuse or addiction. If a selected recipient’s utilization is documented as being excessive, the recipient is restricted to a particular pharmacy and physician.
The program identifies recipients by evaluating drug utilization data in the pharmacy database for the following:
- Excessive quantities prescribed or dispensed
- Lack of a qualifying diagnosis
- Multiple pharmacies or physicians used
- Early refills
Once recipients are identified, HID’s Lock-in Committee reviews each profile and agrees on a specific recommendation. The Committee then arrives at a consensus regarding the recommendation to the Medicaid agency. If the patient is “locked in,” the recipient can use the pharmacy benefit only if he obtains his controlled drugs from the lock-in pharmacy. On a regular basis, the Committee reviews all cases and determines whether different actions should be taken based on each recipient’s behavior.
Features
- Expertise. HID’s Lock-in Committee is made up of pharmacists, nurses, a licensed clinical social worker, and a physician.
- Experience. The Lock-In Committee follows a clearly defined course, based on historical experience, to determine the final recommendation regarding each recipient.
- Consistency. All cases are re-reviewed periodically.
- Analysis. RxCorCare identifies physicians with questionable prescribing habits and pharmacists with questionable dispensing activities.
- Coordination. The Lock-In Committee connects the recipient with the lock-in pharmacy.
- Educational intervention. Letters are sent to the recipient, physician(s), and pharmacist(s) every step of the way.
- Reporting and follow-up. HID provides monthly reporting of all activities to the client.
- Customizability. The client has authority to determine and control all RxCorCare activities.
Benefits
- Prevention of duplication of service by providers
- Avoidance of inappropriate or unnecessary utilization of medical assistance
- Improved health and safety for recipients
- Continuity of medical care
- Decreased costs
For more information on how RxCorCare can help your organization, contact us.