Module 2 (Billing & Reinbursement) Flashcards
It is a set reimbursement
Capitation
This is a amount pay based on the service delivered
Fee for service
Typically, PMs wheelbase contract reimbursement on the lowest of one of the three pricing structure
Usual and customary ( u &C) -sometimes referred to as the “cash price”
-I contracted rate based on the medication, average wholesale price. (AWP) plus a dispensing fee her prescription.
- The maximum allowable cost (MAC) set by the PBM which can differ from pharmacy to pharmacy.
What is the 340 B discount agreement is called?
A PPA. (Pharmaceutical Pricing Agreement)
-Manufacturer agrees to upfront “discount “ on drugs sold to specify providers,
- Specified providers are referred to as “cover entity”
-It is designed for consumers for low income
-for underserved populations
- it s not to billed private insurance
What is the purpose of 340B for the program intended?
Is to “stretch “ federal monies in order to reach more patients, and provide more comprehensive services to the most valuable members of the US population.
What is 340B the program?
Is a federal program created in 1982, which requires pharmaceutical manufacturers to enter into a discount agreement with the government, so those manufactures drugs can be covered under Medicaid and Medicare.
What is considered a 340B “Covered Entity”?
Includes 6 categories of hospitals:
- DSH s - disproportionates share hospitals
- children, hospitals, exempt from Medicare prospective payment system
- Cancer hospitals, exempt from Medicare prospective payment system
- sole community hospitals (lone sources of inpatient care within a geographical area)
- Rural referral centers
- critical access hospitals
Ownership of “ covert entities” must fall in to one of three categories:
1 - state or local government
2- public/private nonprofit corporation rented government powers by the state or local government
3- private nonprofit organization contracted with state/local government to provide care for low income, individuals not qualify for Medicaid or Medicare
Claim scrubbing :
Usually offer by third-party companies to detect and eliminate errors in billing codes.
- Essentially an audit process before it is submitted to the insurance.
- in pharmacy, this can be added as an automatic process.
Switching processing:
They switch is what router to the third-party prescription claims to the PBM or health plan associated with the prescriptions. Within seconds, the script list to pharmacy, go to the switch, then is received at the proper PBM. The claim is excepted or denied, sent back to the switch, and ultimately sent back to the pharmacy.
NPI ( National Provider Identifier)
—10-digit number that identifies a specific provider or entity-stays with that provider for lies once assigned-not insurance specific.
-Providers must use their NPI when transmitting any health information in electronic format.
Key component in identifying fraud: no license prescribers, sanctioned, prescribers, medical identity theft and suspicious prescribing activities.
Provider transaction access number (PTAN):
— Medicare, only number is issued to providers by Medicare administrative contractor (MAC) upon enrollment to medicare .
— the NPI number must be used to bill the Medicare program, and the PTAN (provider Transaction Access Number) will use to at authenticate the provider when using MAC
The lifecycle of a prescription into :
-1-Data entry.
-2-Clam is transmitted electronically.
-3–Claim is adjudicated
-4–prescription is filled by licensed pharmacy staffand check my license Pharmacist.
-5- Prescription is ready for pick up
Dispense as written (DAW) : 9 codes Total
0- no product selection indicated
1- substitution not allowed by prescribe
2- substitution allowed-patient requested that brand product be dispensed.
3 – substitution allowed- Pharmacist select product, dispense.
4– l’substitution allowed — generic drug not in stock
5– substitution allowed —Brand drug dispense as generic override
6– override
7– substitution not allowed -brand drug mandatory by law
8– substitution allowed— generic drug not available in market place
9–-other
claim information
Patient ID
Date of birth.
Gender.
Location of patient is sometime needed like home, Hospital, nursing home facility, etc.
Date of service.
Physician information, example name, NPI, and sometime DEA
Drug information (NDC’s is used to determine coverage)
Processor control number (PCN) and bank identification number (BIN)
Dispense as written code(DAW)
Pieces of the claim information defined
Process a control number (PCN)
Bank identification number (BIN)
National drug code (NDC’s)
Dispense as written (DAW) nine codes total (1 thru 9
A process in which a pharmacy all medical provider submit a claim to the insurance company and receives an approval/denial of payment based on the benefits or coverage requirements
Claim adjudication
Electronic adjudication is a real time building that uses several pieces of information to process the claim: patient information, prescriber, information, medication, date, and place of service, dosing, drug information, plan design (co-pay five dollars, or $10)
— pharmacy clams are considered to have a real time building where areas medical claims do not
Electronic adjudication is a real time building that used several pieces of information to process the claim :
Patient information.
Prescriber information.
Medication
Date and places of service.
Dozing.
Drug information
Plan design(DAW)
Plants divide medication covered on the formulary into a different color restriction knows as
Most plants have a 4 tier’s system
Medication will fall into one of the tiers which will determine coverage and copayment amount.
Patient may ask for a tear exception for trucks in higher chairs under certain circumstances, typical financially related.
Tier 1 -Lois, copy, usually generic drugs, preferred.
Tier 2– high co-pay, can be non-preferred, generic, or preferred brand
Tier 3– highest copy, usually drugs that are non-preferred brand or DAW brands with a generic
Tier 4– specialty drugs that usually require a PA, could be a co-pay charge, or a percentage of the cost
PTAN
Provider transaction access number
Medicare only number issue to provide by Medicare administrative contractor (MAC) upon enrollment to Medicare
The NPI number must be used to build a Medicare program, and a PTAN will be used to authenticate the provider when using Mac
