financial issues chapter 14
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| 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
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| Pharmacy benefit managers | companies that administer drug benefit programs
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| online adjudication | the resolution of prescription coverage through the communication of the pharmacy to computer with the third party computer
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| co-insurance | an agreement for cost sharing between the insurer and the insured
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| co-pay | the portion of the price of medication that the patient is required to pay
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| Maximum allowable cost | MAC- maximum price per tablet or other dispensing unit, an insurer or PBM will pay for a given product
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| 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
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| dual co-pay | copays that have two prices: one for generic and one for brand medications
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| Third party programs | another party besides the paient or the pharmacy that pays for some or all of the cost of medication
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| Public and private healthcare programs | Medicaid and medicare
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| private healthcare programs | HMOs or basic health insurance companies
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| 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
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| important considerations before filling a patients prescription | generic substitution may be required, may be limits on quantity dispensed, per fill or frequency
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| examples of Pharmacy Benefit Managers | Argus, Caremark, Cigna Healthcare, Express Scripts, Medco Health Solutions, MedImpact, ScriptNet, Walgreens Health Solutions
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| 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
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| 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
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| Prescription drug benefit card | Card third party billing information for prescription drug purchasess that contain
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| 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
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| Formulary | a list of medications covered by third party plans
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| Tier | categories of medications that are covered by third party plans
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| What information does a prescription drug benefits card have on it | billing information for pharmacies, patient id number, group number and co pay amount
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| 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
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| most managed care programs require what | generic substitution when a generic available
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| HMO | Health maintenance organization
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| PPO | Preffered provider organization
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| POS | Point of Service programs
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| 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
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| HMOs usually will not cover | expenses incurred outside of their participating network
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| 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
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| POS's generally require | generic substitutions
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| PPOs are a | network of providers contracted by the insurer. PPOs offer the most flexibility for their members
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| HMO's, PPO's, and POS's use | PBM and Pharmacy benefit drug card
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| Medicare | a federal program that covers people over the age of 65 as well as disabled people under 65, and people with kidney failure
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| Medicare part A | covers inpatient hospital expenses for patients who meet certain conditions, and it may also cover some hospice expenses
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| Medicare part B | Covers doctors services as well as some other medical services that are not covered by part A.
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| Medicare Part D | Medicare prescription drug plan- requires participants to pay monthly premium and also met certain deductibles and copayments.
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| MTMS | Medication therapy management services
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| Who provides MTMS benefits | Pharmacists
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| Medicaid | a federal-state program for eligible individuals and families with low incomes, usually operated by state welfare offices
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| Who determines the formularies for medicaid | each state
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| Medicaid recipients can also participate in | HMO programs
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| Workers compensation | an employers compensation program for employees accidentally injured on the job
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| Patient assistance prescription programs | manufacturer sponsored prescription drug programs for the needy
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| what happens during online adjudication? | the tech uses the computer to determine the exact coverage for each prescription with the appropriate third party
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| 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
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| What is considered non patient information | NABP number, prices, co-pay
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| 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
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| DAW | Dispense as written
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| 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
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| DAW indicator 0 | No DAW
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| Daw indicator 1 | DAW handwritten on the prescription by the prescriber
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| DAW indicator 2 | patient requested brand
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| DAW indicator 3 | Pharmacist selected brand
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| DAW indicator 4 | Generic not in stock
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| DAW indicator 5 | Brand name dispensed but priced as generic
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| DAW indicator 6 | N/A
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| Daw indicator 7 | Substitution now allowed; brand mandated by law
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| DAW indicator 8 | Generic not available
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| during the online adjudication process, a claim is rejected sometimes as it is submitted and before what starts | before the prescription is dispensed
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| 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
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| 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
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| Prescriber not a network provider | common to Medicaid, sometimes seen with HMO programs. Only prescriptions issued by network prescribers are covered by the insurer
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| NDC not covered | common with state Medicaid program and managed care programs with closed formularies, Insurer has limited coverage of prescription drugs
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| UCF | Universal claim form
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| Universal claim form | a standardized form accepted by many insurers
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| 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
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| Disease management services sold by PBM's include what illnesses | diabetes, hypertension, asthma, smoking cessation and cholesterol management
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| appropriate standard billing forms for healthcare providers, such as physicians to bill for services | CMS-1500 form, formerly HCFA 1500 form
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| Medicare part D provides MTMS to who | some medicare beneficiaries that are taking multiple medications or have certain diseases.
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| What form is used for billing MTMS through prescription drug plans (pdps) | CMS-1500
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| 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
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| CPT code for Pharmacist provided services 99605 | used for a first encounter with a patient and may be billed in 1-15 minute increments
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| CPT code for pharmacist provided services 99606 | Used for follow up encounters and may be billed in 1-15 minute increments
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| 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
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| 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
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| Prescription Drug Plans | third party programs for medicare part D
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| NPI | National provider identifier, the code assigned to recognized health care providers; needed to bill MTMS
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| Current Procedural Terminology Codes | CPT codes, identifiers used for billing pharmacist provided MTMS
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| CMS-10114 | 6 pages, standard form used by healthcare providers to apply for a national provider identifier
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