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.