Billing and Reimbursement

What is the federal program that provides healthcare coverage for low-income patients or others that meet certain criteria?

Medicaid

What part of Medicare provides prescription drug coverage?

Medicare Part D

When a prescription is not paid by a third-party payer, the prescription is said to be

rejected

When a prescription needs to meet certain criteria before being covered, the prescription will need to go through the ____ process.

prior authorization

The portion of the payment a patient is responsible for is called a(n) ____

copay

True or false: Prescriptions that have no copay do not need to be scanned at the register.

false

A flexible spending account uses ____ income to pay for healthcare-related expenses.

pre-tax

True or false: Members in a preferred provider organization (PPO) can only go to in-network providers.

false

Employees who are injured on the job may be eligible for ____ .

worker's compensation

What is a third-party payer?

the insurance company that may cover a portion or all of the cost of a member's prescription medication

Prescriptions are submitted for payment through the pharmacy processing system to the insurance company. What is this process called?

adjudication

When an insurance company limits the quantity of medication a member can receive, this is an example of a(n) ____.

plan limitation

When patients have more than one insurance company, a(n) ____ must occur to determine which plan is the primary insurance.

coordination of benefits

In fee-for-service methodology, providers are reimbursed for ____.

services provided

____ is prescription drug coverage for members of the military and veterans.

Tricare

"Describe the role of third-party payers in prescription drug reimbursement."

"Third-party payers, such as private insurance and public health insurance, process patients' prescriptions for reimbursement, covering the costs based on the patient's insurance coverage."

"Explain the difference between an HMO and a PPO."

"An HMO (Health Maintenance Organization) requires patients to use in-network pharmacies and often mandates generic prescriptions, while a PPO (Preferred Provider Organization) allows patients to use out-of-network providers at a higher cost."

"Define Medicare and its significance."

"Medicare is a national insurance program for adults aged 65 and older and individuals with disabilities, providing essential health coverage through various parts."

"Do pharmacy employees need to know about payment types?"

"Yes, all pharmacy employees should be familiar with the cash drawer system to accept various payment types, including cash, debit and credit cards, checks, and payment assistance cards."

"Explain the function of the Centers for Medicare and Medicaid (CMS)."

"The CMS is responsible for administering the Medicare and Medicaid programs, which provide government-funded health insurance."

"What is the requirement for patients under an HMO regarding pharmacies?"

"Patients under an HMO must utilize only in-network pharmacies that have agreements with the HMO to fill their prescriptions."

"How does a PPO benefit patients financially?"

"A PPO benefits patients by offering lower costs for services when they use preferred providers, although they can also choose out-of-network providers at a higher cost."

"Describe the importance of understanding billing and reimbursement for the PTCB exam."

"Understanding billing and reimbursement is crucial for the PTCB exam as it prepares pharmacy technicians to handle payment processes and insurance claims effectively."

"What types of payment methods should pharmacy employees be familiar with?"

"Pharmacy employees should be familiar with cash, debit and credit cards, checks, and payment assistance cards."

"Describe Medicaid and its target beneficiaries."

"Medicaid is a state-run insurance program designed for individuals and families with little to no income, including persons with disabilities."

"Explain the purpose of TRICARE."

"TRICARE is a government-sponsored health plan that provides medical coverage for military personnel and veterans, including prescription benefits through the Veterans Health Administration."

"Define workers' compensation and its benefits."

"Workers' compensation is a program that offers medical and prescription benefits to employees injured on the job, with benefits varying by state law."

"How does third-party resolution work in healthcare insurance claims?"

"In third-party resolution, when patients present their insurance card, the information is entered into a computer system, and a claim is sent to the insurance company for payment or rejection."

"What is the purpose of prior authorization in pharmacy claims?"

"Prior authorization is required for certain drugs to ensure proper prescribing before an insurance company approves a pharmacy claim, which can take 24 to 48 hours for review."

"Explain the process of adjudication in pharmacy claims."

"Adjudication is the process of evaluating and either paying or rejecting a submitted pharmacy claim, with the insurance company indicating the covered amount and any patient responsibility."

"Define ICD codes and their use in healthcare."

"ICD codes are used to bill for various medical conditions and procedures, and may be required by insurance companies when submitting pharmacy claims, such as in prior authorization requests."

"What is a copay in the context of prescription claims?"

"A copay is the portion of the payment that the patient is responsible for after a prescription claim has gone through adjudication, often structured in a tiered system based on drug categories."

"Describe the process for handling a prescription with a $0 copay."

"Even if a prescription has a $0 copay, it still needs to be scanned at the register for record keeping purposes."

"Explain common reasons for rejected claims by third-party payers."

"Common reasons for rejected claims include mistakes such as wrong date of birth, wrong gender, incorrect name, too soon to refill the prescription, or an unallowable days' supply."

"Define plan limitations in the context of third-party payers."

"Plan limitations refer to restrictions placed by third-party payers on certain medications or patients, such as quantity limitations or mandatory mail order for specific drugs."

"How does a Pharmacy Benefits Manager (PBM) function in the prescription process?"

"A Pharmacy Benefits Manager (PBM) is contracted by insurance companies to process claims for their members, often using a formulary to help contain costs."

"Explain the difference between an open formulary and a closed formulary."

"An open formulary allows coverage of non-formulary drugs at a higher cost, while a closed formulary does not cover non-formulary drugs at all."

"Describe the purpose of medication assistance programs."

"Medication assistance programs aim to provide drugs at a lower cost to patients, often requiring qualification based on criteria such as income level or disease state."

"What role do coupons play in prescription medication costs?"

"Coupons issued by drug manufacturers can cover the whole or partial cost of certain drugs and may be available to self-paying patients or those with insurance."

"Do some patients have the option to self-pay for prescriptions?"

"Yes, some patients may not have a prescription drug program issued by a third-party payer and can choose to self-pay for their medications."

"Describe how flexible spending accounts can assist patients with drug costs."

"Flexible spending accounts allow patients to use pre-tax dollars to pay for covered items, helping to offset the cost of their drugs."

"Explain the role of pharmacies in home health services."

"Pharmacies provide home health services such as IV home infusion therapy and support for patients transitioning from hospital to home, especially for elderly patients managing multiple new medications."

"Define the services provided by long-term care pharmacies."

"Long-term care pharmacies offer medication dispensing, immunizations, and medication therapy management services to patients in facilities like skilled nursing homes and assisted living homes."

"How do pharmacies manage home infusion for patients?"

"Pharmacies prepare IV medication solutions and deliver them to patients at home, often as part of a home health program."

"Do patients with multiple insurance plans need to coordinate benefits?"

"Yes, patients with more than one third-party payer must coordinate benefits to determine which plan is primary for payment, often requiring them to submit claims to each insurance company."

"Explain the fee-for-service methodology in healthcare reimbursement."

"The fee-for-service methodology involves billing for each individual service provided, which can be used in areas like home health and long-term care."

"Describe the importance of transitional care for elderly patients after hospital discharge."

"Transitional care is crucial for elderly patients as they often need assistance managing multiple new medications after being discharged from the hospital."

"How do flexible spending accounts vary across states?"

"The specific plans and coverage options for flexible spending accounts can differ from state to state."

"What is the episode-of-care approach in healthcare reimbursement?"

"The episode-of-care approach involves reimbursing providers for all services related to a specific treatment or condition over a defined period."

What does Medicare Part A cover?

Hospital insurance

What does Medicare Part B cover?

Medical insurance

What is Medicare Part C?

A Medicare Advantage Plan for additional coverage

What does Medicare Part D cover?

Prescription drug coverage/insurance

What is the difference between hospital insurance and medical insurance?

While hospital plans focus on in-hospital treatments, health insurance covers a broader range of medical services but with limits on the scope and extent of cover for each service.