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chapter 14

financial issues chapter 14

QuestionAnswer
Why such a huge increase in the cost of prescription drugs inflation, the increasing number in the aging elderly population, use of new medications that enhance the quality of healthcare
Pharmacy benefit managers companies that administer drug benefit programs
online adjudication the resolution of prescription coverage through the communication of the pharmacy to computer with the third party computer
co-insurance an agreement for cost sharing between the insurer and the insured
co-pay the portion of the price of medication that the patient is required to pay
Maximum allowable cost MAC- maximum price per tablet or other dispensing unit, an insurer or PBM will pay for a given product
U&C or UCR the maximum amount of payment for a given prescription, determined by the insurer to be a usual and customary (and reasonable) price
dual co-pay copays that have two prices: one for generic and one for brand medications
Third party programs another party besides the paient or the pharmacy that pays for some or all of the cost of medication
Public and private healthcare programs Medicaid and medicare
private healthcare programs HMOs or basic health insurance companies
What do third party programs allow patients to do benefit from new and often more expensive drug therapies than they would otherwise be able to afford
important considerations before filling a patients prescription generic substitution may be required, may be limits on quantity dispensed, per fill or frequency
examples of Pharmacy Benefit Managers Argus, Caremark, Cigna Healthcare, Express Scripts, Medco Health Solutions, MedImpact, ScriptNet, Walgreens Health Solutions
Basic Private Healthcare may pay for prescribed expenses when the patient if covered by a supplementary comprehensive major medical policy or when the patients coverage includes an additional prescription drug benefit
Patients covered by comprehensive major medical policys Pay out of pocket for their prescriptions. Once a deductible is met, the insurer may pay a portion of the cost of prescriptions filled for the rest of the year
Prescription drug benefit card Card third party billing information for prescription drug purchasess that contain
Deductible of medications that are covered by third A set amount that must be paid by the patient for each benefit period before the insurer will cover additional expenses
Formulary a list of medications covered by third party plans
Tier categories of medications that are covered by third party plans
What information does a prescription drug benefits card have on it billing information for pharmacies, patient id number, group number and co pay amount
Managed care program include HMOs and POS's, PPO's. Managed care provides all needed medical care in return for a monthly premium and copays
most managed care programs require what generic substitution when a generic available
HMO Health maintenance organization
PPO Preffered provider organization
POS Point of Service programs
HMOs are made of a network of providers who are either employed by the HMO or have signed contracts to abide by the policies of the hmo
HMOs usually will not cover expenses incurred outside of their participating network
POS programs are usually made of a network of providers contracted by the insurer. patients enrolled in a POS choose a pcp who is a provider in the insurers network
POS's generally require generic substitutions
PPOs are a network of providers contracted by the insurer. PPOs offer the most flexibility for their members
HMO's, PPO's, and POS's use PBM and Pharmacy benefit drug card
Medicare a federal program that covers people over the age of 65 as well as disabled people under 65, and people with kidney failure
Medicare part A covers inpatient hospital expenses for patients who meet certain conditions, and it may also cover some hospice expenses
Medicare part B Covers doctors services as well as some other medical services that are not covered by part A.
Medicare Part D Medicare prescription drug plan- requires participants to pay monthly premium and also met certain deductibles and copayments.
MTMS Medication therapy management services
Who provides MTMS benefits Pharmacists
Medicaid a federal-state program for eligible individuals and families with low incomes, usually operated by state welfare offices
Who determines the formularies for medicaid each state
Medicaid recipients can also participate in HMO programs
Workers compensation an employers compensation program for employees accidentally injured on the job
Patient assistance prescription programs manufacturer sponsored prescription drug programs for the needy
what happens during online adjudication? the tech uses the computer to determine the exact coverage for each prescription with the appropriate third party
How are most community pharmacy computer programs designed so the label doesn't print until the payment source is received from the insurer or PBM
What is considered non patient information NABP number, prices, co-pay
information required for online processing of claims Cardholder id,group #,name,birthdate,sex, relation to cardholder,spouse /dependant/other, date RX written/dispensed,new/refill,NDC,DAW indicator,# needed,Days supply,ID# of physician,ID of pharmacy,ingredient cost, dispensing fee,total price,copay,balance
DAW Dispense as written
In some programs if a patient if given a brand name med when a generic is available, the patient what has to pay the difference
DAW indicator 0 No DAW
Daw indicator 1 DAW handwritten on the prescription by the prescriber
DAW indicator 2 patient requested brand
DAW indicator 3 Pharmacist selected brand
DAW indicator 4 Generic not in stock
DAW indicator 5 Brand name dispensed but priced as generic
DAW indicator 6 N/A
Daw indicator 7 Substitution now allowed; brand mandated by law
DAW indicator 8 Generic not available
during the online adjudication process, a claim is rejected sometimes as it is submitted and before what starts before the prescription is dispensed
Reasons for rejections of insurance claims by third parties dependent exceeds age limit, invalid birth date, invalid person code, invalid sex, prescriber not a network provider, unable to connect w/ insurer computer, patient not covered, refill too soon, refill not covered, NDC not covered
invalid person code the person code (001,002,003) doesn't match the person code for the patient with the sex and birthdate info on the insurers computer
Prescriber not a network provider common to Medicaid, sometimes seen with HMO programs. Only prescriptions issued by network prescribers are covered by the insurer
NDC not covered common with state Medicaid program and managed care programs with closed formularies, Insurer has limited coverage of prescription drugs
UCF Universal claim form
Universal claim form a standardized form accepted by many insurers
What is the procedure with pharmacies with in house billing departments A monthly bill is mailed to the family member or legal representative, who then pays the pharmacy. usually for older patients who live alone, but have someone else taking care of their bills
Disease management services sold by PBM's include what illnesses diabetes, hypertension, asthma, smoking cessation and cholesterol management
appropriate standard billing forms for healthcare providers, such as physicians to bill for services CMS-1500 form, formerly HCFA 1500 form
Medicare part D provides MTMS to who some medicare beneficiaries that are taking multiple medications or have certain diseases.
What form is used for billing MTMS through prescription drug plans (pdps) CMS-1500
in order to bill PrescriptionDrugPlans for MTMS, what has to happen the pharmacist or pharmacy offering the services must be enrolled as a provider for the patients PDP and also have a National Provider Identifier
CPT code for Pharmacist provided services 99605 used for a first encounter with a patient and may be billed in 1-15 minute increments
CPT code for pharmacist provided services 99606 Used for follow up encounters and may be billed in 1-15 minute increments
CPT code for pharmacist provided services 99607 An add on CPT code to be used with 99605 or 99606 when additional 15 minute increments of time are spent face to face with a patient
Medication Therapy Management Services Services provided to some medicare beneficiaries who are enrolled on medicare part D and who are taking multiple medications or have certain diseases
Prescription Drug Plans third party programs for medicare part D
NPI National provider identifier, the code assigned to recognized health care providers; needed to bill MTMS
Current Procedural Terminology Codes CPT codes, identifiers used for billing pharmacist provided MTMS
CMS-10114 6 pages, standard form used by healthcare providers to apply for a national provider identifier
Created by: megancarter