Ask The Pharmacist: How Digital Health Tools Help Claim Handlers Spot Risk Earlier
Jonathan Rowell, Pharm. D.
Pharmacist, Clinical Operations
How can digital health tools help identify claim risks sooner?
Digital health tools can give claim handlers earlier warning signs when a claim is starting to drift.
In workers’ compensation and auto casualty claims, risk often shows up before the claim becomes visibly complex. A missed follow-up visit. Low therapy participation. Worsening pain. A concerning medication pattern. A delay in accessing care.
Digital tools help surface those signals earlier, so claim handlers can ask better questions, involve the right clinical resources and keep the claim moving.
Where Digital Tools Can Spot Early Claim Risk
Claim handlers are often managing provider access, treatment plans, medication use, return-to-work timing, documentation and communication between multiple parties at the same time.
Digital health tools make certain risk signals easier to see, including:
- Missed or delayed follow-up visits
- Low therapy participation
- Worsening pain reports
- Prolonged opioid exposure
- Concerning drug combinations
- Behavioral health concerns
- Inconsistent mobility progress
- Gaps between the treatment plan and actual participation
When those signals are identified earlier, claim handlers can decide whether the claim needs clinical review, provider outreach, pharmacy support, behavioral health resources or closer monitoring.
Telehealth Can Reduce Delays in Care
Virtual visits help injured individuals access care sooner, especially in rural or underserved areas where specialists may be limited.
Telehealth is useful when location, transportation, scheduling or provider availability delays care. It also supports faster access to physicians, behavioral health professionals, physical therapists and pharmacists.
Claim Handler Signal to Watch
If the injured individual is missing appointments, waiting a long time for a specialist or struggling to access care, consider whether virtual care is available and clinically appropriate.
Behavioral Health Platforms Can Flag Recovery Barriers
Behavioral health concerns can slow recovery, even when the physical injury seems straightforward.
Anxiety, depression, post-traumatic stress disorder (PTSD), chronic pain and fear about returning to work can contribute to missed therapy, increased pain complaints, more complex medication use or delayed return to work.
Claim Handler Signal to Watch
If a claim shows delayed recovery, low treatment participation, escalating pain reports or fear about returning to work, psychosocial concerns may be affecting recovery.
Predictive Tools Can Help Identify High-Risk Claims Earlier
Claim handlers may not have time to connect every risk signal across medical records, prescriptions, billing data, imaging reports and claim history.
Predictive analytics can flag patterns that require earlier review, including opioid misuse risk, delayed recovery, treatment gaps, billing concerns or psychosocial complications.
Claim Handler Signal to Watch
A predictive alert should prompt a closer look but not replace clinical review or human judgment.
Digital Pharmacy Monitoring Can Reveal Medication Risk
Medication patterns are often early warning signs of claim complexity.
Prolonged opioid use, risky drug combinations, duplicate therapies, early refills, multiple prescribers or poor adherence are all red flags. These issues can contribute to delayed recovery, safety concerns, dependence risk and higher claim costs.
Claim Handler Signal to Watch
Talk to the pharmacy benefit manager when medication use raises concerns about safety, appropriateness, duration or alignment with the injury.
Remote Monitoring Can Show Whether Recovery Is on Track
Remote therapeutic monitoring tools track rehabilitation exercises, mobility progress, treatment participation and patient-reported pain.
For musculoskeletal injuries, these tools help show whether the injured individual is completing therapy, regaining movement or reporting worsening pain.
Claim Handler Signal to Watch
Low participation, reduced activity, missed home exercises or worsening pain may point to barriers that need follow-up before recovery stalls.
Connected Vehicle Data Can Support Auto Claim Review
In auto casualty claims, connected vehicle technologies and telematics can add useful context.
Advanced driver assistance systems, vehicle diagnostics and crash telemetry may help clarify crash severity, mechanism of injury and whether reported treatment patterns appear consistent with the event.
Claim Handler Signal to Watch
When crash data and treatment patterns do not appear to align, the claim may need medical review or further investigation.
Digital Health Tools Have Limits
Digital tools are only useful when the data is secure, relevant and easy for the injured individual to use.
Privacy, cybersecurity, regulatory requirements, reimbursement rules and access to technology all matter. A tool the injured individual cannot use will not help the claim.
Claim handlers should also avoid relying too heavily on automated alerts. Digital signals can point to risk, but complex claims still need clinical judgment, human outreach and hands-on review.
What Claim Handlers Should Do Next
Digital health tools help claim handlers see risk earlier but the real benefit comes from knowing what to do with the signal.
When a digital tool flags missed care, medication risk, delayed recovery, low therapy participation or behavioral health concerns, claim handlers have a clear reason to intervene. That may mean asking more targeted questions, involving a pharmacist, requesting clinical review, coordinating with the provider or escalating the claim for additional support.
Used well, digital health tools can help claim handlers catch small warning signs before they become bigger claim problems.
This information is intended as a general overview. Specific medical or medication-related questions should be reviewed with a health care professional, such as the prescribing physician or dispensing pharmacist.
Do you have a workers’ compensation or auto-related pharmacy question? Send us an email at AskThePharmacist@enlyte.com.
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