The Golden Rules of Prescribing: A Guide for Insurance Claims Managers
Master the five principles of best-practice prescribing to assess whether medications in your claims align with evidence-based standards.
Published 4 April 2026
Introduction
When you review prescriptions in your insurance claims, how do you know whether a medication is appropriately prescribed? What distinguishes thoughtful, evidence-based prescribing from prescribing patterns that expose your claimant to unnecessary harm? The golden rules of prescribing provide a framework to answer these questions with confidence.
These five principles, grounded in pharmacological and clinical evidence, represent the foundation of safe and effective medication management. They apply across workers compensation, CTP, life insurance, and NDIS schemes. By understanding these rules, you gain the ability to assess medication appropriateness, identify prescribing that deviates from best practice, and make informed decisions about whether a medication warrants approval, modification, or specialist review.
This guide equips you with the assessment framework used by pharmacists and prescribers to evaluate medication appropriateness. It's your practical toolkit for claims decision-making.
The Five Golden Rules of Prescribing
| Rule | What Good Practice Looks Like | Red Flags for Claims Managers |
|---|---|---|
| Right Drug | Medication choice aligns with diagnosis, evidence-based guidelines, and claimant-specific factors (age, renal function, comorbidities, interactions). Documented justification for drug selection. Evidence that less harmful alternatives were considered and rejected for documented reasons. | Medication prescribed without clear link to documented diagnosis. Use of higher-risk medication when safer evidence-based alternatives exist. No documented rationale for drug choice. Drug contraindicated due to claimant's other conditions or medications. |
| Right Dose | Dose is evidence-based, individualised for claimant weight, age, renal/hepatic function, and other medications. Initial dose is typically at lower end of evidence-based range, with clear documentation of rationale for increases. Dose adjustments follow documented clinical reasoning. | Dose is higher than recommended evidence-based maximums without documented justification. Rapid dose escalation without clinical trigger or reassessment. No consideration of claimant age, renal function, or polypharmacy factors in dose setting. |
| Right Duration | Duration of therapy is defined at initiation, with clear planned review dates. Regular reassessment documents continued clinical need and justification for ongoing supply. Medications prescribed with intention to cease are systematically weaned when treatment goals achieved. Exit strategy documented. | Indefinite prescribing without defined endpoint or planned review. Renewals without documented reassessment of continued need. Medication prescribed indefinitely despite achieving clinical goals. No documented plan to cease treatment. |
| Right Patient | Medication is selected considering claimant's full clinical picture, including comorbidities, allergies, previous medication reactions, pregnancy/breastfeeding status, preferences, and capacity to manage medication appropriately. Documentation of assessment and exclusion of contraindications. | Medication prescribed without documentation of allergy history or previous adverse reactions. Inappropriate prescribing for age group (e.g., benzodiazepines in elderly). No consideration of claimant's ability to comply with medication regimen. Contraindication not identified or addressed. |
| Right Monitoring | Monitoring plan is documented and proportionate to medication risk profile. For higher-risk medications (opioids, benzodiazepines, anticoagulants), monitoring includes clinical assessment, objective measures where applicable, and regular prescriber and patient contact. Monitoring results documented and acted upon. | High-risk medications prescribed with no documented monitoring plan. Monitoring ordered but results not documented or acted upon. No evidence of prescriber-patient contact to assess medication effectiveness, compliance, or harm. Absence of addiction risk screening for opioids. |
Rule 1: The Right Drug
The right drug for your claimant is determined by three factors: diagnosis, evidence-based guidelines, and claimant-specific characteristics.
Diagnosis and Evidence Alignment
Before approving a medication, confirm the prescription is linked to a documented diagnosis. The medication should be evidence-based for that diagnosis. For example, gabapentin is evidence-based for neuropathic pain but not for osteoarthritis; opioids are appropriate for acute post-operative pain but require careful justification for chronic non-cancer pain. Check whether the prescriber has documented clinical reasoning for this medication choice in the claimant's specific context.
Safer Alternatives Considered
Good prescribing involves considering less harmful alternatives and explicitly documenting why they weren't suitable. For opioid prescribing, you should expect to see documented evidence that non-opioid pain management (physiotherapy, psychological therapy, NSAIDs where appropriate) has been trialled or considered. If the claimant has used alternative medications previously, good prescribing documents why those failed and why this new choice is necessary.
Patient-Specific Factors
The right drug differs for different claimants. Age, renal function, hepatic function, other medications, comorbidities, allergies, and pregnancy status all influence whether a drug is truly the right choice for your specific claimant. Look for documentation that these factors have been considered. For example, benzodiazepines are relatively contraindicated in elderly claimants due to increased falls risk; quinolone antibiotics may be relatively contraindicated in claimants with connective tissue disorders.
Rule 2: The Right Dose
Dosing is where prescribing practice often deviates from evidence-based guidelines, creating unnecessary risk in your claims.
Evidence-Based Starting Doses
Best practice initiates therapy at an evidence-based dose, typically the lower end of the therapeutic range. This allows assessment of tolerance and efficacy before escalation. If your claimant starts on a dose higher than recommended evidence-based ranges, the prescriber should document clinical justification. For example, if a claimant starts oxycodone at 20mg twice daily when evidence-based guidelines recommend starting at 5-10mg, there should be documented reasoning (e.g., previous opioid tolerance, severe acute pain requiring higher initial dose).
Individualised Adjustments for Patient Factors
Renal and hepatic function affect medication metabolism. Elderly claimants typically require dose reductions due to reduced drug clearance. The right dose accounts for these factors. Review documentation to see whether renal or hepatic function has been assessed, and whether doses have been adjusted accordingly. For medications like metformin, dosing may need significant reduction with renal impairment; failure to do so increases toxicity risk.
Systematic Dose Escalation with Clinical Justification
When doses are increased over time, each increase should be preceded by documented clinical assessment. For opioids specifically, evidence-based guidelines recommend slow titration with regular assessment between increases. If your claimant's opioid dose doubles or triples in a short timeframe without documented reassessment of pain, function, or clinical change, that's a red flag for prescribing that has departed from best practice.
Dose Ceilings and Evidence-Based Maximums
Most medications have evidence-based maximum doses. For example, standard evidence-based guidance suggests that for chronic non-cancer pain, opioid doses above 90-120mg morphine equivalent daily require careful specialist assessment due to escalating overdose risk. If your claimant is prescribed above recommended maximum doses without documented specialist involvement or clear clinical justification, escalate for medication review.
Rule 3: The Right Duration
Duration of therapy is particularly important for time-limited medications. Many medications in your claims should have a defined endpoint and exit strategy.
Planned Review Dates and Defined Duration
Best-practice prescribing defines the intended duration upfront. For example, a course of antibiotics has a clear endpoint; a prescription for post-operative pain relief should define how long opioids will be used and when reassessment will occur. When you review a claim, look for documentation that the prescriber defined an endpoint and planned review date at the time of prescribing.
Regular Reassessment of Continued Need
Medications should be regularly reassessed. For chronic medications, prescriber notes should document the clinical justification for continued supply: Is the claimant's condition improved, stable, or worsening? Is the medication achieving its therapeutic goal? Is the claimant tolerating the medication? Each prescription renewal ideally includes a reassessment note, not just a repeat without review.
Systematic Cessation and De-prescribing
When treatment goals are achieved, medications should be systematically ceased. For medications with withdrawal risks (opioids, benzodiazepines, some antidepressants), cessation should involve gradual dose reduction with documented withdrawal management. In your claims, if a claimant achieved clinical improvement but continues indefinite medication supply, that's a red flag. Ask the prescriber about the exit strategy and plans to de-prescribe when treatment goals are met.
Particularly Important for Time-Limited Conditions
In workers compensation and CTP schemes, many injuries are time-limited. Once the claimant reaches maximum medical improvement, ongoing medications require reassessment. Some medications appropriate for acute injury recovery may not be appropriate for chronic maintenance.
Rule 4: The Right Patient
The same medication that's ideal for one claimant may be inappropriate or harmful for another.
Full Clinical Assessment and Contraindication Screening
Right-patient prescribing begins with comprehensive assessment. You should see documentation that the prescriber has taken an allergy history, reviewed previous medication reactions, considered comorbidities, and screened for contraindications. For example, ACE inhibitor blood pressure medications are contraindicated in pregnancy; NSAIDs are contraindicated in some cardiac conditions; statins may be inappropriate in certain muscle disorders.
Age-Appropriate Prescribing
Age significantly influences medication appropriateness. Benzodiazepines and anticholinergic medications carry high falls risk in elderly claimants. Opioids are particularly risky in older adults due to altered pharmacokinetics and increased overdose sensitivity. Paediatric doses differ substantially from adult doses. Look for documentation that age has been considered in medication selection and dosing.
Assessment of Medication Compliance Capacity
The right patient is someone who can reliably use the medication as intended. Claimants with cognitive impairment, active substance use disorders, or limited health literacy may struggle to take medications safely. Good prescribing either simplifies regimens (once daily rather than four times daily) or integrates support. If your claimant has risk factors for non-compliance, look for documentation of how the prescriber is addressing this (simplified regimen, supervised administration, etc.).
Special Populations: Renal and Hepatic Impairment
Claimants with renal or hepatic impairment require medication selection and dosing adjusted for reduced drug clearance. If your claimant has documented renal or hepatic disease, check whether medications and doses have been adjusted. Medications cleared primarily by the kidney (many antibiotics, beta-blockers) may accumulate to toxic levels if doses aren't adjusted for impaired renal function.
Rule 5: The Right Monitoring
Monitoring is often the weakest link in prescribing practice and is a critical focus area for claims managers.
Risk-Stratified Monitoring Plans
Monitoring should be proportionate to medication risk. A low-risk hypertension medication might require blood pressure checks several times per year. A high-risk medication like opioid pain relief should include more intensive monitoring including regular clinical contact, addiction risk screening, and assessment of dose justification. Benzodiazepines should include documentation of legitimate clinical need and planned de-prescribing strategy.
Documented Monitoring for Opioids and Benzodiazepines
For your most commonly-problematic medications, look for clear monitoring evidence. For opioids, you should see documentation of: regular prescriber and patient contact; assessment of pain levels and function; assessment for signs of opioid-related harm (oversedation, respiratory depression); addiction risk screening; and justification for dose continuation or escalation. For benzodiazepines, you should see documentation of continued clinical need (is the patient still experiencing anxiety or insomnia?) and planned cessation strategy.
Objective Measures and Reassessment
Monitoring isn't just clinical impression; it includes objective measures where relevant. For diabetes medications, HbA1c should be regularly measured. For anticoagulants, INR (where relevant) should be monitored. For medications affecting renal function, creatinine and eGFR should be regularly checked. Review whether objective monitoring has occurred and whether results have influenced prescribing decisions.
Documentation and Action on Monitoring Results
Monitoring is only valuable if results inform prescribing decisions. Look for documentation that monitoring has occurred and that results have been reviewed and acted upon. If a claimant's pain isn't improving on current opioid doses after months of therapy, has the prescriber documented reassessment and considered whether escalation is justified or whether alternative approaches are needed? If monitoring reveals renal function decline, has the medication been adjusted?
Integrating the Golden Rules Into Your Claims Assessment
Step 1: Confirm Right Drug
Check that medication is linked to documented diagnosis and that prescriber has documented rationale for this specific choice. Verify safer alternatives were considered.
Step 2: Assess Right Dose
Compare prescribed dose to evidence-based guidelines for the indication. Check that renal and hepatic function have been considered. If dose is above maximum recommended, look for specialist documentation.
Step 3: Verify Right Duration
Confirm prescriber has defined intended duration and planned review dates. For ongoing medications, check recent reassessment notes confirming continued clinical need.
Step 4: Confirm Right Patient
Review documentation of allergy screening, contraindication assessment, and age-appropriate prescribing. Verify any special population factors have been addressed.
Step 5: Review Right Monitoring
Check that monitoring plan is documented and risk-appropriate. For high-risk medications, verify regular clinical contact and reassessment documentation exists.
When to Escalate for Medication Review
Consider referring for pharmacist-led medication review when you identify:
- High-risk opioid prescribing with inadequate documentation of addiction risk screening or monitoring
- Medication doses above evidence-based maximums without specialist justification
- Indefinite medication prescribing without planned review dates or documented continued clinical need
- Polypharmacy involving significant drug interaction risks
- Medications prescribed despite documented contraindications
- Rapid dose escalations without clear documented clinical triggers
- High-risk medications in elderly claimants without evidence of age-appropriate prescribing consideration
Key Takeaways for Claims Managers
The five golden rules of prescribing provide a practical framework for assessing medication appropriateness in your claims:
- Right drug: Medication is evidence-based for the diagnosis, safer alternatives have been considered, and patient-specific factors support this choice.
- Right dose: Dose is evidence-based, individualised for the patient, and increases are supported by documented clinical reasoning.
- Right duration: Duration is defined upfront, regular reassessment documents continued need, and exit strategy is planned.
- Right patient: Patient has no relevant contraindications, allergies have been screened, and age-appropriate prescribing has been applied.
- Right monitoring: Monitoring is risk-proportionate and documented; results inform prescribing decisions.
When prescribing in your claims aligns with these five principles, you can have confidence it represents evidence-based practice. When prescribing deviates from these principles without clear documented justification, that's your signal to escalate for specialist assessment. A medication review through an independent pharmacy service can provide clarity on whether prescribing aligns with evidence-based best practice and where adjustments might reduce harm and improve claimant outcomes.
Need to assess whether medications in your claim follow evidence-based prescribing principles? IMM's medication reviews provide independent pharmacist assessment of whether prescribing aligns with the golden rules and current guidelines.
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