Reimbursement Flashcards
This is done when an Insurance company is trying to prevent fraud or suspects fraud. Evaluate if a pharmacy is in compliance with insurance contract plan guidelines for the pharmacy and state and federal regulations
Audit
Early refills.
Duplicate fills.
Quantities that exceeds plan limits
Wrong quantity
Wrong days supply calculation.
“Use as directed “instructions
Wrong drug or strength
What data entry errors can an audit uncover
Verify, the correct patient has been selected.
Double check the insurance information is accurate
Verify the correct medication and directions have been entered.
Compare the prescription to the information entered into the computer.
Pull the stock bottle from the shelf and scan it, so the correct NDC has been selected
Make sure the stock bottle NDC matches what’s been entered or scanned
Don’t rush while performing data entry.
Enter the correct DAW code
Calculate the days supply correctly.
Perform a final review of the information that has been entered into the computer
What do you do to minimize the number of data entry errors at your pharmacy?
The drug program that helps hospitals and clinics, providing care to the most vulnerable patients, the uninsured, underinsured, people with HIV or aids, and kids with cancer by requiring drug companies to provide medication at a discounted price.
340B Program
A federal program that requires drug manufacturers participating in the Medicaid drug rebate program to provide covered outpatient drugs to enrolled “covered entities” at or below the statutorily defined ceiling price.
340B drug pricing program
A facility/program that is listed in the 340B status as eligible to purchase drugs through the 340B program and appears on the 340B OPAIS.
It refers to a healthcare provider organization that is eligible for the 340B program per the fourth 340B statute.
340B covered entity
The maximum drug price manufacturers can charge a covered entity for a 340B purchased covered outpatient drug.
340B ceiling price = Average manufacture price (AMP) - Unit Rebate Amount (URA)
A unique identification number provided by HRSA to identify a 340B-eligible entity in 340B OPAIS. .
340B ID : it used to purchase 340B program
The 340B it provides access to the covered entity and manufacturer records, user accounts, change requests, recertification, and registrations.
340B OPAIS( office of pharmacy affair information system)
What is the difference between WAC and AWP
The difference between the WAC (what the pharmacy actually paid for the drug) And the reimbursement from insurance (based on AWP know as the spread, and equate to the price that pharmacy receipt) space market price on the brand-name tends to be roughly 15% higher than DAWP
 AWP is the price of medication before discounts or rebates
Most the party plans used by formula based on a AWP for reimbursement
What does DNV?
DMV means the Norwegian truth originated in Northway in 1864 as a risk management company the mission is dedicated to safeguarding life property and the environment. It has two goals to access compliance and educate hospitals in this practice

What does Joy commission do?
The joint commission focuses On quality care for the American public through a voluntary independent evaluation process it goes is to help hospital to become hi reliability organization for delivering safe effective cute.
Sell directly to customer.
A……..pharmacy sells products directly to patient.
Retail
Wholesale companies sell things to other companies who resell the product to customers .
like most businesses pharmacies get the products they sell from a wholesaler.
Wholesale
a pharmacy‘a Purchase price is how much the pharmacy pays for the drug or other product .
This cost includes any discounts, rebates, and other price adjustments that affect with the pharmacy actually pays a wholesaler for the drug
Cost/purchase price
