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OpioidCM

Pre-Workers' Compensation

Predict a Soft Tissue Worker Compensation Claim Before It Is Filed

Opioid prescribing patterns are an early clinical signal for high-cost soft-tissue workers' comp claims. OpioidRx‑PreWC identifies at‑risk employees and refers them to non-surgical care before a claim ever exists.

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Illustrative Impact — 2,000 Employees
Employees eligible for intervention~17
Projected annual savings~$1.9M
AI predictive range70–85%
The Cost You Don't See

Opioid Involvement Multiplies Claim Cost

These costs surface as an orthopedic claim, not an "opioid" line item — by the time dependency is visible, the claim has already escalated.

9X
Cost Multiplier

Average claim cost when opioids are involved, versus a standard claim.

$13K → $117K
Standard vs. Opioid Claim

The average W/C claim settles for ~$13,000; with an opioid Rx for an orthopedic injury, ~$117,000.

25%
Of W/C Drug Spend

Opioids account for roughly a quarter of all workers' compensation prescription drug costs.

Why This Matters

Soft Tissue MSK Injuries Are the Leading Cause of Workplace Disability

Whether from chronic ergonomic strain or an acute slip, trip, fall, or assault, soft-tissue musculoskeletal (MSK) injuries are the #1 driver of work-related injury and disability — and the risk factors are well established.

Heavy Physical Work High Psychosocial Demands Repetitive Tasks Awkward Postures Heavy Lifting

Construction

High rates of occupational injury paired with high prevalence of back and MSK pain.

Commercial Fishing

Physically demanding, high-injury work with limited access to early intervention.

Health Care Support

Nursing aides and similar roles face constant lifting and repetitive strain exposure.

The Business Problem
$13K → $117K
Average W/C claim cost, standard vs. with an opioid Rx for orthopedic injury.
25%
Share of all W/C prescription drug costs made up by opioids.
>3 Months
Opioid use beyond this point — workers usually never return to work at all.1
90%
Of opioid users weren’t worried about dependency — though 60% had a known risk factor.2

1. HR Today. Combatting the Prescription Drug Crisis. March 1, 2016. Accessed at: https://www.shrm.org/hr-today/news/hr-magazine/0316/pages/combatting-the-prescription-drug-crisis.aspx on 09.23.2016.
2. National Safety Council. Prescription Nation 2016: Addressing America’s Drug Epidemic

How OpioidRx‑PreWC Works

From Claims Data to Prevented Claim

Implementation uses existing pharmacy claims. No new software, no PHI required to begin.

1

Blind Rx Data Review

We analyze blinded pharmacy claims — after your standard PBM, TPA, and PDMP reviews have already run.

2

AI Risk Identification

OPCM's proprietary PCAPE engine (Prescription Claims Analytics Preprocessor) structures the data and flags elevated orthopedic / W/C risk, 70–85% predictive.

3

Early Intervention

Identified employees are referred to non-surgical regenerative care — evaluated and treated before a claim is ever filed.

In Partnership with Regenexx

Treatment That Prevents the Claim

Rather than managing a claim after surgery, identified employees are referred to Regenexx for minimally invasive, image-guided regenerative treatment — addressing the orthopedic condition directly, often eliminating the claim entirely.

Why Regenexx Instead of Surgery

  • Minimally invasive, image-guided injections — same-day procedure
  • No surgical risks: infection, DVT, pulmonary embolism, prolonged rehab
  • Lower upfront and downstream cost for payers and employers
  • Faster return to work, less disruption to daily life

What the Duke Studies Show

$45,616

Lumbar spine savings per patient vs. spinal fusion at 12 months

$13,556

Knee savings per patient vs. TKA at 12 months (all p<0.001)

<1%

Subsequent spinal fusion rate, vs. 14% in the surgical group at 4 years

<8.5%

TKA conversion rate, vs. 11.3% TKA revision rate at 12 months

Spine

Disc herniation, degenerative disc disease, nerve pain

Knee

Arthritis, meniscus tear, ACL/PCL/MCL sprain

Shoulder

Rotator cuff tear, labral tear, tendinosis

Hip

Arthritis, bursitis, labral tear

Hand / Wrist / Elbow

Carpal tunnel, arthritis, tennis elbow

Ankle / Foot

Ligament tear, plantar fasciitis, Achilles

Projected Impact — Illustrative Model

What This Could Mean for a 2,000-Employee Group

A worked example using the assumptions in OPCM's Pre-WC model. Your actual results depend on your population and claims history.

2,000
Total Employees
Baseline population
70
Likely to File a Claim
3.5% W/C incidence rate
56
Orthopedic-Related
80% of claims
21
AI-Identifiable
37% predictable by PCAPE
~17
Eligible for Intervention
~80% can be treated pre-claim
~$1.9M
Projected annual savings
for a 2,000-employee group, at an estimated ~$85K+ saved per identified patient.

Source: OpioidRx Pre-Workers' Compensation presentation supplied by OPCM. Predictive and financial figures are presented as stated in the source deck; the 2,000-employee example is illustrative and not a guarantee of results.

Ideal For

  • Self-insured employers with meaningful MSK / orthopedic claim exposure
  • TPAs managing workers' compensation claims and mod ratings
  • Employers seeking pre-claim risk reduction, not just claims management
  • Brokers looking for differentiated W/C value for their book

What We Don't Do

  • We do NOT restrict appropriate access to pain management
  • We do NOT remove physicians or providers from decision-making
  • We do NOT direct care or involve attorneys

Start With a Free No-Cost PCR

We begin with a no-cost review of your paid pharmacy claims to identify your Pre-WC opportunity. No obligation. No PHI required.

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