Insurance For Pharmacy technician training (Unit 2, Lesson 12)

Adjudication

The process where a pharmacy submits a prescription claim to an insurance provider or pharmacy benefit manager (PBM) for payment. This process determines whether the claim is approved, denied, or requires further review

Processor

The company hired by the insurer to process claims

Claim

Request for reimbursement from a healthcare provider to an insurance company for services and products provided

Co-pay

The portion of the cost of a service or product that the patient pays out of pocket each time the service or product is provided

Deductible

The set amount a patient pays up front to healthcare provider before insurance coverage applies, can be paid at once or in multiple payments

Medicare

Federally funded health insurance plan, for individuals 65+, with disabilities, or with end stage renal disease, provides hospital, medical, and prescription insurance

Medicaid

Federal and state joint health insurance plan, for families and individuals with low income or family members with disabilities, administered by state governments, eligibility determined by state

Health maintenance organization (HMO)

Medical needs are addressed by hospitals, doctors, pharmacies, ect that are contracted with the HMO

Requires primary care physician (PCP) that is selected to be first point of contact, then a referral is given to others who are needed, least private health care system available

Preferred provider organization (PPO)

Similar to HMO but with more choose of selecting physicians and other providers, allows in and out of network, does not need referral

In network is cheaper

Drug discounts

Offered by chain retail, manufacturer, or organizations/companies offering patient assistance programs

Patient assistance programs

Good option for high cost or high duration drug regimens, patient enrolls and must be approved by completing drug assistance paperwork

TRICARE

Medical insurance for families of armed service personnel and of those employed for public health service and NOAA

CHAMPVA

Civilian Health and Medical Program of the Department of Veterans Affairs, is a health insurance program for eligible dependents and survivors of certain veterans. It shares the cost of covered healthcare services and supplies with beneficiaries, who typically pay a portion of the cost (25% up to an annual cap)

Worker’s compensation

Insurance for those injured at work, patient not responsible for any costs, which is covered by employer

Open formulary

Covers drugs not listed in formulary

Closed formulary

Where drugs are not listed in the formulary and are not covered without explanation of medical need by doctor, drug would be exception to the rule to be reimbursed

Restricted formulary

Restricts or limits types of drugs to generics or drugs within a certain class

Tier

A particular list of Rx drugs

-Generic

-Preferred brand medications

-nonpreferred drugs

-Biogenerics (includes biologics and specialties)

Drug utilization review

Make sure formulary is used correctly, so patients only receive drugs that are authorized and approved by their insurance

1. Preapproval

2. Check drug against formulary

3. Patient eligibility

4. Correct dosage, check for interactions, ect

5. Sometimes therapeutic interchange, substituting one drug for another in the same class

Preauthorization

Preapproval for a drug before i is prescribed or dispensed

Required by some drug classes such as narcotics, addictive drugs, specialty drugs, and costly drugs

Insurance data

Includes name, marital status, address, DOB, phone number, employment, and carrier, must match data of carrier or the claim will be denied

Transmitting prescriptions to insurance

Needs

Name of medication dispensed, whether generics are available

Strength and dose of medication

Medication name will be matched against insurance’s formulary

DAW code 0

Physician authorized generic

When either patient accepts generic or generic is not available

DAW code 1

Physician requires prescription dispensed as written, no generic allowed

DAW code 3

Physician authorizes generic

Generic is available, but patient refuses generic

Incorrect days supply

If days supply is wrong, it will affect prescription refill times and insurance reimbursement

Patient not covered

Patient was not recognized, can be due to the following reasons:

Wrong name, birthdate, or provider

New coverage can cause lack of recognition since it takes time for the new coverage to show

Too early to refill

Could be caused by incorrect days supply

Healthcare Fraud and Abuse Control Program

Established by HIPAA to catch and persecute any fraud or abuse in healthcare and insurance claims, enforce by Office of Inspector General, FBI and Department of Justice involve in investigating

Cannot

Make false insurance claims

Receive or give kickbacks for services paid for by insurance

Providers cannot have any financial relationship to clinics where they refer patients

Knowing and not acting on crime makes a person an accomplice

Pharmacy information systems

Allows inpatient order entry and management, inpatient prescription dispensing

Outpatient order entry, management, and dispensing

Inventory and purchasing management

Utilization and workload reports + financial reports

Clinical monitoring

Compounding

Intervention management

Medication administration

Connectivity to other systems

Pricing, charging, and billing