POWERPOINT Chapter 16 for 4th edition-2
Chapter 16: Insurance and Billing Overview
Objectives
Understand key terms: deductible, premium, copayment.
Define group and prepaid health plans.
Explain types of private health insurance.
Discuss government insurance plans and eligibility for Medicare and Medicaid.
Describe adjudication processes for insurance claims.
Differentiate codes: ICD-10, NDC, HCPCS.
Identify reasons for coverage rejections.
Key Terms
General Terms: audits, beneficiary, coinsurance, eligibility, health insurance, Medicaid, Medicare.
Types of Insurance: CHAMPVA, TRICARE, Medicare Advantage Plan, prescription coupon cards, etc.
Billing Issues: overpayment, plan limitations exceeded, preauthorization, coordination of benefits.
Healthcare Cost Overview
Rising healthcare costs: $5.6 trillion projected by 2025.
Importance for pharmacy technicians to understand billing processes and insurance claims to ensure payment security, protection against audits, and correct patient copays.
Group Plans/Policies
Group insurance covers employees under a single policy, usually better benefits and lower premiums than individual plans.
Prepaid Health Plans
Policyholders pay regular fees to access services. Providers are compensated via capitation.
Individual Contracts
Personal insurance with higher premiums and fewer benefits compared to group insurance.
Types of Health Insurance
Third-party Payer: Not part of the initial contract, pays on obligations.
Health insurers often contract with pharmacy benefit managers (PBM).
Common Plans/Cards and PBM
Various health insurance cards (e.g., Medicare, TRICARE) and roles of PBM in claims processing, payment, and copay management.
Private Health Insurance Examples
Blue Cross-Blue Shield, various HMOs, and largest insurers like WellPoint and Aetna.
Medicare and Medicaid Overview
Medicare: Primary for seniors and disabled individuals, divided into Parts A, B, C (Advantage), D (prescriptions).
Medicaid: Serves low-income populations with varying copayments.
Claims Processing and Adjudication
Claims submitted electronically; decisions are made by comparing claims to benefits.
Coordination of benefits for multiple payers after the primary has settled.
Importance of thorough patient profiles for accurate billing.
Common Claim Problems and Rejections
Issues include non-coverage of drugs, expired coverage, non-matching patient information, and limits exceeded.
Specific rejections include refill too soon and days supply exceeded.
Special Billing Scenarios
Billing for non-medication items like immunizations and durable medical supplies, requiring proper codes and documentation.
Role of Pharmacy Technician
Technicians must accurately use software for insurance billing and maintain clear communication about patient and prescription details.