Transcript Financial Issues

Financial Issues
Chapter 14
Financial issues
In 1985, the average prescription price
was $10. By 2006 the average price
approached $70.
The increase is due in part from inflation,
the aging population, and new medicines
that enhance the quality of health care.
Third Party Payments
Third party programs are another party
besides the patient or the pharmacy that
pays for some or all the cost of
medication, the insurer.
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Basic health insurance, Medicaid, Medicare,
or HMOs
Pharmacy Tech and the
Prescription Process
The pharmacy tech must understand the
different types of health insurance and
how drug benefits differ among programs.
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Insurance policies may limit the quantity of
medication dispensed, the number of refills,
and generic substitutions may be required,
etc.
Computers and Third Party Billing
Most insurance claims are now filed
electronically by online claim submission
and online adjudication of claims.
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This process benefits both the pharmacy and
third party programs because of improved
accuracy and control of claims. It is also
much faster and more direct than processing
paper claims.
Co-Pays
This is an agreement between the insurer and
the insured to share the cost of the prescription.
The patient must pay a portion of the price of the
medication and insurance company is billed for
the remainder. Will pay the usual and
customary amount depending on geographical
location.
Some have duel co-pays, which means that a
lower co-pay applies to prescriptions filled with
generic drugs and a higher co-pay applies to
prescriptions filled with brand name drugs that
have no generic equivalent.
Third Party Programs
Traditional (private) health insurance
policies have the added benefit of
prescription drug coverage.
Prescription drug benefit cards – card that
contains third party billing information for
prescription purchases.
Managed Care Programs
Health maintenance organizations (HMOs)
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Unlike traditional health coverage, an HMO sets
guidelines under which doctors can operate. Health
care coverage through the use of an HMO costs less
than traditional health insurance, with limitations on
the range of treatments available.
Preferred provider organizations (PPOs)
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A PPO is a group of doctors and/or hospitals that
provides medical service only to a specific group or
association.
Point-of-service programs (POS)
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combines characteristics of the HMO and the PPO.
Public Health Insurance
Medicare – a federal program that covers
people over the age of 65, disabled people
under the age of 65, and people with
kidney failure.
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May purchase a Prescription Drug Plan and
pay a monthly fee.
Some people covered by Medicare have no
prescription coverage.
Public Health Insurance
Medicaid is a federal-state program. State
welfare department usually operate
Medicaid. Each state decides who is
eligible for benefits and what services will
be covered.
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Prescription drug formularies are determined
by each state.
Other Programs
Workers’ Compensation
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Compensation for employees accidentally
injured on-the-job.
Patient Assistance Programs
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Offered by some pharmaceutical
manufacturers to help needy patients who
require medication that they cannot afford and
do not have insurance.
Online Adjudication
In online adjudication, the technician uses the
computer to determine the exact coverage for
each prescription.
The Online Process
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Obtain information from the patient: prescription,
billing information, and personal information.
This information is entered in the computer and is
transmitted to the insurer.
After an online response is received (paid, not paid,
co-pay amount) the pharmacy tech prints a label and
gives the okay to process the prescription.
Pharmacies must keep records to verify that the
prescription was filled and dispensed.
Online Claim Information
Information required for online processing
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Cardholder ID number
Group number
Name of patient
Birth date
Sex
Relationship to cardholder
Date Rx is written
Date Rx is dispensed
Online Claim Information
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National drug code (NDC) of drug
Dispense as written (DAW) indication
Amount or quantity dispensed
Is this a new or refill
Days supply
ID number of prescriber
National Provider Identifier (pharmacy ID)
Medication cost
Dispensing fee
Total price
Deductible or co-pay amount
Rejected Claims
In the online adjudication process, the
insurer sometimes rejects the claim,
Usually rejected can be resolved by the
pharmacy tech either by reviewing the
claim for errors, speaking with the
prescriber, or the insurer.
Common reasons for third party
rejected claims
Dependent coverage expired
Invalid birth date
Invalid person code
Invalid sex
Prescriber not part of network
Unable to connect with insurer’s computer
Coverage is terminated
Refill is to soon
Refills not covered
NDC not covered
Other Billing Procedures
Paper Claims – universal claim form.
In-House Billing procedures – example
elderly with legal custodian filling
prescriptions.
Disease State management Service -IDDM, asthma, hypertension
Medication Therapy Management
Services – Medicare benefit