Third-Party Payers Flashcards
Insurance provided to people who are retired, disabled, have low income, or have military benefits.
Examples: Medicaid, Medicare, TRICARE
Government
Insurances that keep cost low, while providing quality, comprehensive healthcare. Medicaid and Medicare, are government-sponsored:
Examples: HMO, PPO, Medicaid, Medicare
Managed care organizations (MCO)
Insurance that pays for an employee’s healthcare after they’ve been hurt on the job.
Workers’ Compensation
Other ways to help reduce the cost of medication
Examples: Discount cards, drug coupons, assistance programs.
Other Payment Programs
Responsible for the portion of the drug cost the plan doesn’t cover.
Patient
A company that reimburses healthcare providers for their services.
Third-Party Payer
An ongoing amount paid by an individual to maintain insurance coverage. Must be paid regardless if benefits are used or not.
Premiums
Plan-specific limits outlining amounts the patient and the plan will pay during the plan year.
Coverage Stages
Plan-specific list of drugs, covered by the insurance, organized in tiers based on drug cost.
Plan Formulary
Claims are submitted online to the insurance company, then get approved or denied almost immediately. The third-party payer verifies that the patient’s insurance is active and details of the prescription, such as NDC, quantity, days supply, and dose, are within plan limits.
Adjudication
In addition to premiums, some plans require the patient contribute an annual out-of-pocket amount before insurance benefits can be used. At the time of service, the patient cost will be higher to cover the additional amount until this is met.
Deductible
Based on the specific plan, the patient cost at the time of service usually includes this for each drug. These are flat, dollar amount, such as $5, $10, or $20.
Co-pay
Based on the specific plan, the patient cost at the time of service usually includes a co-pay or coinsurance for each drug. This is a percentage of the medication cost such as 15% or 25%.
Coinsurance
Based on the plan details, the amount covered by the third-party payer.
Insurance Benefit
Average price that wholesalers sell a medication
Not regulated by government does not take into account or discount based on volume 
Average wholesaler price (AWP)
Actual acquisition cost the pharmacy pay for the medication 
AAC plus dispensing fee 
Financial accounts, establish by employee for basically financial accounts
family to pay for qualify medical expenses 
HSA . Health saving Account
Special money that u put it a side so u can pay certain out of pocket for healthcare care and u can’t not roll over for next year
FSA
Financial account establish by individual to pay the medical expenses it’s anything like medical expense, vision, glasses, dental vision concept, images,.
It is come by the benefit of both traditional and brass 401(k), and I IRA text 
HSA healthcare savings account
Cost formula=
Purchase price + cost to dispense
Purchase price x discount rate
Discount formula
Purchase price - discount =
Discount price formula
Selling price - purchase price =
Gross profit
Gross profit formula=
Selling price - purchase price
Sum of all expensive =
Overhead
Selling price minus overall cost =
Profit formula
Average price that wholesaler sell a medication
Not regulated by government
Does not take into account discount based on volume
Average wholesale price (AWP
Actual cost is the pharmacy pay for the medication formula
Actual acquisition cost ( ACC) + Dispensing fee
This is used in calculating the reimbursement formulary for generic medication :
Determined by managed care organization
MAC + dispensing fee
Income minus overhead
Net profit
What is fee for service reimbursement?
Fee for service is an amount pay based on the service delivered
What is capitation reimbursement?
Capitation reimbursement is a set reimbursement
