Transcript Chapter 14 Power Point

Financial Issues
Chapter 14
Financial Issues
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Financial issues have a
substantial influence on health
care and pharmacy practice.
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In 1985 the average
prescription price was $10.00.
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In 2002 the average price of a
prescription was about $60.00.
Financial Issues
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Why the increase?
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Inflation
The aging of the population
New treatments
Advances in technology
Direct to consumer advertising
The use of third party programs to pay
for Rx’s has increased in response to
the rising Rx costs.
Financial Issues
Because of the pharmacy technician’s role in the Rx
filling process, you must understand the different
types of health insurance programs and how drug
benefits differ between each program.
Terms
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PBM – Pharmacy benefits
manager: companies that
administer drug benefit programs.
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Online adjudication – the
resolution of prescription
coverage by communication
between the pharmacy’s
computer & the insurer’s
computer.
Terms
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Co-pay – the portion of the price of the medication
that the patient is required to pay.
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MAC (maximum allowable cost) – the maximum
price per tablet (or dispensed unit) that an insurer
or PBM will pay.
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NOTE:
**Pharmacies bill at the time of filling, & will know
a patient’s eligibility, copay and what the insurer
will allow as payment.
Managed Care Programs
HMOs – Health Maintenance Organizations
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HMOs are made up of a network of providers
who are either employed by the HMO or
contractually obligated to abide by the HMO’s
policies.
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Services are covered in network, but not if
outside network providers are used.
Managed Care Programs
POS – Point of Service
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A network of providers where the insured’s
primary care physician (PCP) must be a
member.
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Costs incurred outside the network, may be
partially reimbursed, but patient usually
must have a referral from the PCP.
Managed Care Programs
PPO – Preferred Provider Organization
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A network of providers, contracted by an insurer.
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The patient’s primary care physician (PCP) need
not be a member,
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Costs to the patient are reimbursed according to
the use of the preferred providers. Cost from nonpreferred providers may be partially reimbursed.
Third Party Programs
Medicare
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A federal program that funds health care to people
over 65 years or with certain disabilities.
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Part A – covers inpatient hospital & some hospice
services.
Part B – covers doctor services and some additional
medical services.
Part C – advantage plans; patients can choose to
receive all benefits from a managed plan provider.
Part D – covers prescription drugs
Third Party Programs
Medicaid
 Called Medi-Cal in California
 A federal/state funded program, administered
by the state providing health care for the needy.
Worker’s Compensation
 An employer compensation program for
employees accidentally injured on the job.
Online Adjudication
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In online adjudication, the technician uses the
computer to determine exact coverage for each Rx
with the appropriate third party.
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When brand name drugs are dispensed,
dispensed as written (DAW) numbers must be
entered into the DAW field to ensure proper
payment.
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See codes on page 339
Rejected Claims
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In the online adjudication
process, sometimes the insurer
rejects the submitted claim.
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When a claim is rejected, the
pharmacy tech can call the
insurance plan’s help desk for
assistance in correctly billing
the claim. (Detective work)
Chapter 14
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Read Chapter 14
Review:
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Terms
Third party programs
Online claim process
Online claim
information
DAW codes
Rejected claim issues
Read Key
Concepts
Review Self Test