Controlled Substance Utilization
Promoting safe, responsible prescribing and use of controlled substances
What Is Controlled Substance Utilization Management?
Innovative Care Management’s Controlled Substance Utilization Management services support plans in promoting safe and responsible use of controlled substances through clinical oversight and coordinated intervention.
Prescription medications such as opioid pain relievers and certain anti-anxiety medications can play an important role in treating legitimate medical conditions. However, these medications also carry risks of misuse, dependency, and inappropriate prescribing patterns if usage is not carefully monitored.
ICM’s program helps plans identify concerning patterns early, coordinate with prescribing providers, and connect members with appropriate clinical resources when needed. This approach supports member safety while helping plans manage the risks and costs associated with inappropriate controlled substance utilization.
How We Do It
ICM takes a proactive and coordinated approach to controlled substance monitoring. By reviewing utilization patterns, collaborating with prescribing physicians, and working with plans to implement safeguards, ICM helps ensure controlled substances are used safely and appropriately.
Services Include:
Plan Consultation and Program Design
Implementation of Safeguards
Quarterly Utilization Reviews
Clinical Evaluation of Flagged Cases
Provider Outreach and Care Coordination
Referrals to Additional Resources
Plan Consultation and Program Design
ICM works with the health plan and vendor partners to recommend plan language and program safeguards that support effective controlled substance oversight.
Implementation of Safeguards
Plans may implement safeguards designed to reduce the risk of misuse, such as measures that limit the use of multiple prescribers or pharmacies.
Quarterly Utilization Reviews
ICM registered nurses conduct quarterly reviews to identify high-risk narcotic utilization patterns and unusual prescribing behavior.
Clinical Evaluation of Flagged Cases
When potential high-risk patterns are identified, clinical documentation is reviewed to evaluate the medical necessity and appropriateness of ongoing prescriptions.
Provider Outreach and Care Coordination
ICM communicates directly with prescribing physicians to share findings and coordinate appropriate next steps when concerns arise.
Referrals to Additional Resources
When appropriate, members may be referred to additional clinical resources, including pain management services or chemical dependency treatment programs.
Controlled Substance Utilization in Action
Case Study1
Identifying High-Risk Prescribing Patterns and Supporting Safer Pain Management
A member receiving opioid medication for back pain began filling prescriptions more frequently than prescribed. When an early refill was denied, the member obtained an additional prescription from another provider and filled it at a different pharmacy.
During ICM’s utilization review process, this prescribing pattern was flagged as a potential concern. An ICM nurse contacted the prescribing physicians to share the findings and coordinate care. Through this collaboration, the member’s care team reviewed the treatment plan and explored alternative approaches to managing the member’s pain.
The member was connected with appropriate pain management resources and received support in transitioning to a safer, coordinated treatment plan designed to better address the underlying condition while reducing the risk of medication misuse.
Case Study2
Coordinating Care Following Extended Post-Surgical Opioid Use
During a quarterly utilization review, an ICM registered nurse identified a member who continued filling opioid prescriptions months after a surgical procedure.
ICM contacted the prescribing physician to review the member’s current treatment plan. The physician had not been aware that the medication was still being filled and worked with ICM to reassess the member’s pain management needs.
The member was referred to appropriate clinical resources and supportive services to help address ongoing symptoms and reduce reliance on opioid medication. This coordinated approach helped ensure the member received the care and support needed to continue recovery safely.
Additional Services to Consider
ICM’s Controlled Substance Utilization Management services are part of our Forward-Thinking Care Solutions that help plan sponsors take control of their coverage strategies.
Other Forward-Thinking Care Solutions to consider include:
Healthcare Management Consulting
Our experienced medical management executives provide consulting services tailored to your plan’s needs to help with a plan design that balances your needs with the needs of plan members.
Predictive Data Analytics
Our advanced analytics capabilities can identify high-risk members, predict future healthcare needs, and implement targeted interventions. Actionable insights help plan’s reduce avoidable costs while improving the quality of care and supporting a proactive, member-centered approach.
Cost/Quality Data
With access to robust cost and quality data, we can help members find high-quality and cost-effective providers and identify providers who are known for working with innovative and non-traditional plan designs. The insights empower smarter decision-making that help plans improve outcomes and manage costs.
Frequently Asked Questions
What safeguards can plans implement to reduce misuse of controlled substances?
Why should plans consider Controlled Substance Utilization Management services?
What happens when concerning utilization patterns are identified?
When potential misuse is identified, ICM communicates directly with prescribing providers to coordinate care and evaluate appropriate next steps. ICM may also work with the plan to implement safeguards that help prevent similar situations in the future.