FINANCIAL ISSUES

CHAPTER 14

CHAPTER OUTLINE• Financial Issues

• Third-Party Programs– private health insurance– managed care programs– public health insurance– other programs– coordination of benefits

• Online Adjudication

• Rejected Claims

• Other Billing Procedures• Review

FINANCIAL ISSUES

• Pharmacy Benefit Managers

• Computers & Third-Party Billing

• Co-pays

THIRD PARTY PROGRAMS: PRIVATE HEALTH INSURANCE

• Formularies

• Managed care programs– HMOs– POS programs– PPOs

THIRD-PARTY PROGRAMS:PUBLIC HEALTH INSURANCE

• Medicare– Part A– Part B– Part D• Prescription drugs• Medication Therapy Management (MTM)

• Medicaid

OTHER THIRD-PARTY PROGRAMS

• Workers Compensation

• Patient Assistance Programs

• Coordination of Benefits

INFORMATION NEEDED FOR ONLINE CLAIM PROCESSING

cardholder identification number group number name of patient birth date gender relationship to cardholder date Rx is written date Rx is dispensed new or refill NDC of drug

DAW indicator amount or quantity days supply prescriber identification pharmacy identification/NPI ingredient cost dispensing fee total price deductible or co-pay

amount balance due

THE ONLINE PROCESS DAW INDICATORS

0 No DAW (No Dispense as Written)1 DAW handwritten on the prescription by the prescriber2 Patient requested brand3 Pharmacist selected brand4 Generic not in stock5 Brand name dispensed but priced as generic6 N/A7 Substitution not allowed; brand mandated by law8 Generic not available9 Other

REASONS FOR CLAIM REJECTIONS

• Dependent exceeds age limit as specified by plan• Invalid birth date• Invalid person code• Invalid sex• Prescriber not a network provider• Unable to connect with insurer’s computer• Patient not covered (coverage terminated)• Refill too soon• Refills not covered• NDC not covered

OTHER BILLING PROCEDURES

• Paper claims–universal claim forms

• In-house billing

• Disease state management services–CMS-1500 form

• Medication Therapy Management (MTM) services

BILLING FOR MTM SERVICES• National Provider Identifier (NPI)

• Current Procedural Terminology Codes (CPT codes)

• Examples of online platforms–OutcomesMTM–RxTherapy Management–Mirixa

MTM-BILLABLE SERVICES• Comprehensive Medication Reviews (CMR)

• Prescriber consultations– cost efficiency–drug therapy problems

• Patient consultations– compliance–education–monitoring