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IPC > T3: Third Party > Flashcards

T3: Third Party Flashcards

1
Q

What is a third party?

A

An organization that reimburses a pharmacy or patient for all or part of the patients prescription drug costs

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2
Q

What are the types of third party payers?

A

Public and Private

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3
Q

What are private TPP?

A
  1. Usually an insurance company.
  2. May be a manufacturer or other discount program.
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4
Q

What are public Public TPP?

A

Government entities that pay for prescriptions through a government program.

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5
Q

What is medicare?

A

the government program that provides health insurance for the elderly and disabled, implemented a voluntary Medicare Part D program in 2006.

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6
Q

What is Medicaid?

A

funded jointly by federal and state governments, with each state determining its own prescription drug reimbursement rates.

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7
Q

What are PBMs?

A

Provide prescription claims processing and other services

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8
Q

What type is the most TPP?

A

Private but more recently it has shifted toward public

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9
Q

What is difference between pharmacies and TPP?

A
  1. Pharmacies determine the price they want to charge private pay patient
  2. TPP is determined by a contract between the third party and pharmacy
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10
Q

Describe TP prescriptions?

A

the pharmacy staff must verify patient eligibility, submit and reconcile claims, wait for payment, and comply with third-party rules and requirements, such as formularies.

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11
Q

What are the benefits of TPP?

A
  1. Require that patient obtain their prescription from a network pharmacy, or they may allow patients to use non-network pharamcies
  2. May have preferred pharm network within broad network
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12
Q

What do pharmacies choosing to be a preferred pharmacies obtain?

A

Additional prescription volume, but usulally at the cost of lower reimbursement rates

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13
Q

What is a service benefit plan?

A

The patient may pay the pharmacy a predetermined portion of the prescription cost, but the pharmacy is reimbursed directly by the third party for most of the prescription cost

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14
Q

What are third party reimbursements?

A
  1. Payments are based on a reimbursement-rate formula that is specified in the contract between the pharmacy and the third-party payer.
  2. Product cost + dispensing fee
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15
Q

Most third-party contracts state that the reimbursement rate for a prescription of what lower prices?

A
  1. The price of from the reimbursement rate formula
  2. The usual and customary pharmacy prices
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16
Q

What is Actual acquisition cost (AAC)?

A

The price that the pharmacy pays the drug wholesaler or manufacturer to obtain the drug product.

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17
Q

What is Average actual acquisition cost (AvAC) or (AAAC)?

A

An average of the prices paid by different pharmacies for drug products. Must be determined via pharmacy survey.

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18
Q

What is average manufacturer price (AMP)?

A

The average price received by a manufacturer from wholesalers for drugs distributed to the retail class of trade.

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19
Q

What is average wholesaler price (AWP)?

A

A list price for what drug wholesalers charge pharmacies. This is an overestimate of what the wholesaler actually charges the pharmacy.

20
Q

What is Estimated acquisition cost (EAC)?

A

The third-party’s estimate of what the pharmacy pays the drug wholesaler or manufacturer.

21
Q

What is Generic drug utilization rate (GDUR)?

A

The percent of prescriptions at a pharmacy that are dispensed with a generic drug. Also called generic dispensing rate.

22
Q

What is is Generic effective rate (GER)?

A

The average third-party reimbursement rate for generic prescription drugs across all generic drug products.

23
Q

What is Maximum allowable cost (MAC)?

A

The maximum cost that the third party will pay for a multisource drug. This typically is an average of the generic drug price from several manufacturers.

24
Q

What is Wholesaler acquisition cost (WAC)?

A

A list price for what pharmaceutical manufacturers charge drug wholesalers. This is an overestimate of what manufacturers actually charge wholesalers.

25
Q

What is the bank ID number (RX bin)

A

used to identify how a prescription drug will be reimbursed and where a pharmacy can send a reimbursement claim to

26
Q

What is the processor control number (Rx PCN)?

A

secondary identifier that may be used in routing of pharmacy transactions. A PBM/processor/plan may choose to differentiate different plans/benefit packages with the use of unique PCNs

27
Q

What is the group number (Rx group)?

A

your employer identification number. Health insurance providers assign a GRP number to each employer plan.

28
Q

Describe the PBM money flow route?

A
29
Q

What is ID number/member Id/Subscriber ID?

A

patient specific. May end with a different number if coverage includes more than one person (person code).

30
Q

How many prescriptions have been filled by paying third party?

A

89%

31
Q

Describe third part rejections (TPRs)?

A
  1. Resolving these rejections takes time and effort
  2. Communicating the status of a patients rejected prescription is another opportunity to build trust
32
Q

What are the types of common TPRs?

A
  1. Prior authorization (75)
  2. Non formulary item (MR)
  3. Refill too soon (79)
  4. Plan limitations exceeded
  5. Cost exceeds maximum
  6. Submit to primary (41)
33
Q

What are prior authorization?

A
  1. Requires documetation from prescriber
  2. May take several days to resolve
  3. No guaranteed approval
  4. May have higher copay
34
Q

What communications are used during prior authorization?

A
  1. Communicate with prescriber via fax, phone, or electronic message.
    Communicate with patient/caregiver in their preferred method.
35
Q

What do non formulary item require?

A
  1. Requires changing medication.
  2. Patient/Prescriber may be able to submit an appeal.
  3. Often alternatives will be presented.
36
Q

What communications are used for non-formualry item?

A
  1. Communicate with prescriber via fax, phone, or electronic message.
  2. Communicate with patient/caregiver in their preferred method.
37
Q

What are required for refill too soon?

A
  1. Requires setting a prescription to fill on a future date.
  2. Insurance may allow for overrides in special circumstances.
38
Q

What communications are involved with refill too soon?

A

Communicate with patient/caregiver in their preferred method.

39
Q

What is required when plan limitation exceeded?

A
  1. Requires a change in quantity/days supply.
  2. Rejection screen should indicate what amount will be covered within a specified time period.
40
Q

What is required for cost exceeds maximum?

A
  1. May require an override.
  2. May require a change in quantity/day supply.
41
Q

What is required to submit to primary?

A
  1. Patient has another prescription insurance company.
  2. May require patient reaching out to both companies.
42
Q

What communications are involved with plan limitations exceeded?

A

Communicate with patient/caregiver in their preferred method.

43
Q

What communications are involved with cost exceeds maximum?

A
  1. Communicate with prescriber as necessary.
  2. Communicate with patient/caregiver in their preferred method.
44
Q

What communications are involved with submit to primary?

A

Communicate with patient/caregiver in their preferred method.

45
Q

How do we resolve TPRs?

A
  1. Rx accepted/entered at pharmacy
  2. Insurance company returns a rejection in real time
  3. Inform the patient/caregiver
  4. Notify prescriber and provide guidance for next steps
  5. Communicate outcome to patient/caregiver

IPC (41 decks)

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