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PHM115 Insurance
CH 8 Healthcare and Prescription Drug Insurance
| Question | Answer |
|---|---|
| What's the importance of insurance to address raising prescription drug costs? | |
| Insurance: Commercial | also called private insurance; coverage for medical or prescription costs provided by an employer or purchased by an individual |
| Insurance: HMO | |
| Insurance: PPO | private practice prescriber that has signed a contract with the health insurer to provide services at a discounted rate. |
| Insurance: Workers' Compensation | insurance provided for a patient with a medical injury from a job-related accident |
| Insurance: Medicare Part A | fed sponsored insurance plan that covers 80% of the cost of hospital stays, limited coverage of skilled nursing facilities, rehab and home health care, drugs not covered under this plan |
| Insurance: Medicare Part B | fed sponsored insurance that partially covers the cost of outpatient doctor visits, may cover the cost of nebulizer and nebulizer medication and diabetic supplies |
| Insurance: Medicare Part D | federal and state partnered insurance program that provides partial coverage of prescriptions, primarily for patients who are eligible for Medicare |
| Insurance: Medicare Part C | fed and state sponsored insurance that covers health and prescription insurance from the same insurance provider; also called Medicare Advantage plan; may include coverage for eye and hearing exams, glasses, hearing aids, etc. |
| Insurance: Medigap | private insurance coverage in addition to Medicare Pt B that covers a portion of the costs for outpatient physician visits as well as lab and xray fees not covered by Med Pt B |
| Insurance: Medicaid | state government health insurance program for low income and disabled citizens |
| Insurance: Cobra | Insurance policy where a former employer is required to keep a former employee on the employee insurance plan at full premium cost for 18-36 months. |
| Insurance: Children's Health Care Insurance (CHIP) | Similar to medicaid, low cost to free healthcare insurance program run jointly by fed and state, aimed at uninsured children from ages 0 to 19 whose parents earn over fed poverty line but too little to afford healthcare insurance for their children. |
| Insurance: Affordable Healthcare Exchanges | online source where eligible individuals and families can comparison shop for insurance plans within their price range, established by the ACA (Affordable Care Act) |
| Insurance: Supplemental Health Insurance | |
| Insurance: Tricare Prime | |
| Insurance: Tricare Extra | |
| Insurance: Tricare Standard | |
| Insurance: Tricare for Life | |
| Insurance: Pharmacy Benefits Manager (PBM) | division of insurance company or separate company that insurance contracts with to process patient prescription claims |
| Key term: Average Wholesale Price (AWP) | the average price that pharmacies, hospitals, and other healthcare facilities pay for stock of a specific drug. Serves as a benchmark from which insurance companies estimate the percentage of pharmacy reimbursement. |
| Key term: monthly premium | cost for health insurance coverage, referred to also as an enrollment fee. |
| Key term: insurance policy | health services and products outlined in plan for what the patient is eligible to receive |
| Key term: benefits | the health insurance services and products in the insurance plan |
| Key term: deductible | designated amount of annual medical costs that must be paid for by the patient before the coverage of the insurance company fully kicks in. |
| Key term: copayment | flat out-of-pocket fee a patient is required to pay, usually for RXs, office visits, services or products |
| Key term: coinsurance | like a copay, but certain percentage patient must pay with any potential further billing to come later. |
| Key term: tiered copay | copay is determined by type of service/product...generic vs brand drugs, dr visit vs ER visit, etc... |
| Key term: in-network providers | prescribers and pharmacies that have a contract with the insurance provider, insurance generally covers more |
| Key term: out-of-network providers | prescribers and pharmacies that do not have a contract with the insurance provider, cost of services generally higher and insurer generally covers less |
| Key term: prior authorization | some drugs require prior approval from PBM before being prescribed (eg. drug atypical for age, gender, condition; drug not on the PBM formulary; patient already prescribed similar drug, etc) |
| Key term: pharmacy benefits manager (PBM) | company that administers drug benefits for many insurance companies. |
| Key term: coordination of benefits (COB) | patient has multiple insurances; billing to primary insurance first, then secondary; there still be amount left over to be paid by patient. |
| Key term: online adjudication | refers to the process of electronically submitting prescription claims to the appropriate PBM for its judgment on whether or not it will provide reimbursement. |
| What is the concept of tiered copayments for private commercial drug insurance programs? | insurance coverage in which patient has escalating copay, generally generic - preferred brand drug - non preferred brand drug - higher tiers may include expensive specialty drugs. |
| Describe the Affordable Health Care Act's expansion of Medicaid and state healthcare exchanges to help provide coverage for those who are underinsured or uninsured. | |
| What is technician's role in identifying and resolving errors in online adjudication? | |
| What is the technician's role in explaining insurance drug coverage to patients? | Being able to effectively explain and communicate to customers the insurance drug coverage, why something wasn't covered or covered at different amount, prior authorization, etc... Patients often confused by the myriad of insurance issues that can arise. |
| How does a technician assist financially struggling patients through medication assistance advocacy? | Generic drug recommendations, free or lower cost prescriptions, drug discount coupons and cards, refer to Healthcare Exchange for affordable program, ask if they may be eligible for state's medicaid or state-run healthcare assistance programs. |
| What are the steps to resolve problems with audits and chargebacks? | verify details of original prescription and supplemental documentation , patient profile, and adjudication process. find documentation that patient actually received the prescription. respond to audit timely, within 2 weeks of receipt of the challenge. |
| Audit | PBM might request check on pharmacy's prescription records to challenge problems. audits intended to reduce fraud and waste. correct billing and documentation of prescriptions is critical in this process. |
| bank identification number (BIN) | info located on most drug insurance cards to identify the correct PBM, the BIN, PCN, group, and patient ID # are all necessary to process the drug claim |
| capture the claim | where pharmacies achieve reimbursement confirmation from the PBM |
| catastrophic insurance | low monthly premium, high deductible, very few if any preventative services. Aimed to cover person who experienced severe accident or unexpected debilitating illness/disease. |
| certificate of medical necessity (CMN) | documentation, including diagnosis codes, needed for Medicare Part B coverage of DME |
| charge-back | rejection of a prior prescription claim by a PBM or an insurance provider that must be investigated and resolved. |
| CPT | Type of insurance billing code: Current Procedural Terminology; to record procedures and services |
| days' supply | the correct amount of medication to fit the prescription duration until refill or end of use. |
| Defense Health Agency (DHA) | administers Tricare, federal government health insurance for active and retired military personnel and their dependents. |
| discount card | drug companies will offer discount couponsfor their products to prescribers or individuals. many for high cost brand name drugs, are patient assistance discount programs online; may not be accepted by all pharmacies, techs need to carefully reviewed. |
| donut hole | insurance coverage gap in Medicare Part D programs under which the patient must pay a higher portion of the cost of medication; due to be phased out in 2019 |
| dual copay | patient pays one copay for Brand name drugs and a lower copay for generic drugs, also known as two-tier |
| dual eligible | some elderly patients are eligible for both Medicaid and Medicare. ALSO can mean, primary insurance and secondary insurance. |
| durable medical equipment (DME) | hospital beds, wheelchairs, walkers |
| first party | party responsible for covering a medical bill (eg. patient, parent, or guardian) |
| flexible spending account | patients, through their employer, can place pretax dollars aside for medical expenses AND child/dependent care expenses. Usually not able to be carried over from one year to next, some plans have $500 carryover allowed for certain circumstances. |
| group number | identifies the employer sponsor of the drug insurance program |
| HCPCS | Type of insurance billing code: Healthcare Common Procedures Coding System, to record supplies, equipment, and devices supplied for medical purposes |
| health savings accounts (HSAs) | savings type plan where patients or their employers can set aside pretax money specifically for healthcare costs.. Can be carried over from one year to next. |
| ICD-10 | Type of insurance billing code: International Classification of Diseases, 10th addition; to record diagnoses and disorders |
| second party | health care provider |
| third party | insurance company or it's management representative, usually billed first |
| What is the average price that PBMs reimburse a pharmacy? | U&C |
| Usual and Customary (U&C) charges | negotiated rate that includes cost of drug and pharmacy dispensing fee; negotiated between each insurance company and each pharmacy. |
| By law, pharmacies cannot charge or negotiate a higher cost to the government programs than to a commericial user or PBM for the same prescription | True |
| Processor control number (PCN) | on insurance card; identifies the correct PBM in order to process the prescription claim. |
Created by:
ChemeketaPHM2021
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