Clinical Oversight

When a Physician Peer Review secures written agreement from a treating physician to change inappropriate pharmacy treatment, it does not automatically produce a new, appropriate drug regimen. Additionally, CMS will not reduce pharmacy allocations based only on a physician’s agreement to a new drug regimen. Medicare requires evidence that the treating physician has discontinued inappropriate medications and is actively prescribing a new drug regimen. That’s where our Pharmaceutical Clinical Oversight comes in.

Once a treating physician agrees to change pharmacy therapy, our Pharmaceutical Clinical Oversight engages registered nurses to track cases. They:

  • Check with treating physicians before and after an injured worker’s medical appointment to make sure medication changes are discussed
  • Determine the patient’s level of cooperation
  • Obtain copies of medical records for each office visit
  • Provide reports to clients
  • Follow subsequent appointments as an injured worker tapers off or completely discontinues the use of opioids and other drugs
  • Determine how patients are faring with any new medications
  • Compile medical records and other evidence that CMS requires to show that the patient has stabilized on the new pharmacy regimen

We help determine when sufficient evidence has been gathered to support the new treatment regimen and recommend the timing of an MSA’s submission to CMS or other settlements.

Because future pharmacy costs on lifetime claims are so high, Pharmaceutical Clinical Oversight, coupled with Physician Peer Review, is one of the best places to spend your claims cost-containment dollars. For more information, call 888.331.4941, email, or refer a claim.