On Opioids - The Claims Professionals' Perspective
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By NCCI Insights May 2, 2018

This article is the second installment of NCCI’s series On Opioids. This series is aimed at exploring three viewpoints on issues surrounding opioid use and workers compensation: those of doctors, insurers, and regulators. NCCI conducted interviews with professionals from each of these areas and the articles in this series reflect their opinions on the topic.

In this second of our three-part series, we hear from several claims management professionals in the workers compensation (WC) industry—including insurance company representatives and a third party administrator (TPA).

Talking to Claims Professionals

The dangers of opioid use have been on the radar of insurers and TPAs since the mid-1990s. Developing ways to address overuse and manage the long-term use of such drugs took many years. These responses continue to evolve through a combination of increased understanding of the opioid epidemic, new tools and data, and a changing regulatory environment.

Claims professionals say there are five key elements that are critical to successfully managing the use of opioids:

  • Early identification and recognition of the risk of addiction
  • Rigorous monitoring of the injured worker throughout the life of the claim
  • A team approach to pain management
  • A regulatory environment conducive to managing prescribing practices
  • Healthcare literacy

Early Identification of Risk

Claims professionals know that WC claims involving prescribed opioid painkillers tend to be associated with workers who have more severe injuries or illnesses. These claims typically result in longer recovery periods for the worker, delayed return to work, and an increased chance of becoming problematic due to the addictive nature of opioids. Thus, early identification of injured workers who are at greater risk of addiction was cited as a key to successful claims management. Some carriers have developed tools to help identify those risk factors and now work to prevent the addiction before it ever happens.

Claims triage was also mentioned as an essential early step in the process, and it can take several forms. Some organizations depend on the experience of the claims adjuster to assess the risk of an individual claimant. Others report using a more systematic approach, utilizing predictive models to flag claims so that nurse case managers and claims professionals can participate with the treating physician to develop a successful treatment plan for the worker. One interviewee reported that implementing a system that flags the claim and includes case review has resulted in a decrease in costs and a reduction in average claim duration.

Continued Monitoring

The claims professionals we spoke with recognized the importance of communication between the claims department and the treating physician. They reported that when they communicated regularly and effectively with the physician, more favorable outcomes were evident. However, they also noted significant differences in the amount of interaction, in part due to legal or regulatory impediments. For example, some states may limit contact with a physician or require the claims professional to first contact the claimant’s attorney in order to speak with the treating physician. Both of these examples were highlighted as potentially leading to delays in the overall process.

The claims professionals also said that close monitoring of the injured worker’s functional improvement and adherence to the prescribed treatment plan are critical and sometimes help to identify needed changes in the treatment. However, changing the treatment plan for an injured worker can be difficult, they said. Often the worker has an established regimen of opioid therapy and may already be dependent on the drugs.

For workers receiving a steady stream of prescriptions, claims professionals reported some benefits from using services such as physician-operated drug utilization reviews. This process involves peer-to-peer communication between a clinician and the prescribing physician. Claims adjusters use this tool to find opportunities to wean injured workers off opioids and seek alternatives such as acetaminophen and ibuprofen, physical therapy, or other treatments. One adjuster stressed the importance of asking the doctor for a plan to stop the use of opioid medication following the very first prescription.

Team Approach

Collaboration between the claims professionals, nurse case managers, treating physicians, other experts, and the injured worker is considered critical to a positive treatment outcome by those we interviewed. The insurance company or representative provides a claims adjuster, a nurse case manager and, in more complex situations, the expert advice of an experienced practitioner to assist the physicians in treating the injured worker. The importance of bringing in the appropriate medical expertise was emphasized.

Additionally, addressing psychosocial factors was also cited as a key element. This requires the whole team to work in concert to achieve the desired results, at times even bringing in the injured worker’s family.

Claims Infographic

Regulatory Environment

The claims professionals also spoke about the complexity of navigating varied rules among states. They felt that it was, at times, easier to handle claims in employer-directed states than in states where the employee chooses the provider. For instance, some claims professionals reported that doctors who were chosen by the claimant were more likely to have a longer standing treatment relationship with the injured worker. This more established relationship may result in added sympathy from the physician, sometimes leading them to more readily prescribe opioids to the worker, the claims professionals said.

Also, employers that have greater engagement with injured employees and designated physicians at the outset are more likely to experience a positive outcome for both the injured worker and the employer, according to one claims professional.

As for other state regulations, they noted that rules regarding opioid prescribing and the use of prescription drug monitoring programs can indeed be useful to identify a prescribing pattern and manage opioid utilization. Other valuable rules that were mentioned included drug formularies and treatment guidelines. Several mentioned that these rules are successful in Texas, and not only from a perspective of decreased costs, but also because the prospective authorization of drug treatments has been associated with a reduction in prescribing opioids.

Healthcare Literacy

Claims professionals expressed concern about the lack of healthcare literacy among injured workers. There was a consensus that these workers may still not be fully aware of the negative effects that opioids can have on them. Consequently, injured workers may not have enough information to advocate for alternatives to opioid treatments.

Some claims professionals questioned whether the pursuit of alternative treatments has yet to widely take hold, while others have seen some success with alternative treatments. Every person is different, and there is no one-size-fits-all plan for treating chronic pain, the adjusters said. They admitted that alternatives to opioid treatment—like acupuncture, life-coaching, and cognitive behavioral therapy—were viewed skeptically in the past. But, in recent times, adjusters report seeing medical practitioners direct more injured workers to these alternatives. Claims professionals also reported a shift to other pharmacologic alternatives such as gabapentin, Lyrica®, and nonsteroidal anti-inflammatory drugs like ibuprofen.


Managing workers compensation claims that involve opioids can be very complex and include many players—all of whom are critical to a positive outcome. Early detection of the risk of addiction, continuous monitoring, and adherence to a treatment plan, along with a regulatory environment conducive to an expedited resolution of issues, are notable features of success. Adopting alternatives and enhanced healthcare literacy regarding the effects of opioids can be vital in addressing the opioid epidemic in workers compensation.

Stay tuned for our next installment, On Opioids—The Regulators’ Perspective, which will focus on the experience of industry regulators dealing with the opioid epidemic in workers compensation. At our Annual Issues Symposium 2018, we’ll explore opioids and workers compensation further as we present OpioidsKiller Pain Relief.

Special thanks to organizations that generously shared their thoughts: Amerisure Insurance, Chubb, and Gallagher Bassett.

This article is provided solely as a reference tool to be used for informational purposes only. The information in this article shall not be construed or interpreted as providing legal or any other advice. Use of this article for any purpose other than as set forth herein is strictly prohibited. The articles in this series reflect the viewpoints of the experts we interviewed and do not necessarily represent the views of NCCI.