Third-Party Payers

Question 1

Insurance provided to people who are retired, disabled, have low income, or have military benefits.

Examples: Medicaid, Medicare, TRICARE

Answer 1

Government

Question 2

Insurances that keep cost low, while providing quality, comprehensive healthcare. Medicaid and Medicare, are government-sponsored:

Examples: HMO, PPO, Medicaid, Medicare

Answer 2

Managed care organizations (MCO)

Question 3

Insurance that pays for an employee’s healthcare after they’ve been hurt on the job.

Answer 3

Workers’ Compensation

Question 4

Other ways to help reduce the cost of medication

Examples: Discount cards, drug coupons, assistance programs.

Answer 4

Other Payment Programs

Question 5

Responsible for the portion of the drug cost the plan doesn’t cover.

Answer 5

Patient

Question 6

A company that reimburses healthcare providers for their services.

Answer 6

Third-Party Payer

Question 7

An ongoing amount paid by an individual to maintain insurance coverage. Must be paid regardless if benefits are used or not.

Answer 7

Premiums

Question 8

Plan-specific limits outlining amounts the patient and the plan will pay during the plan year.

Answer 8

Coverage Stages

Question 9

Plan-specific list of drugs, covered by the insurance, organized in tiers based on drug cost.

Answer 9

Plan Formulary

Question 10

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.

Answer 10

Adjudication

Question 11

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.

Answer 11

Deductible

Question 12

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.

Answer 12

Co-pay

Question 13

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%.

Answer 13

Coinsurance

Question 14

Based on the plan details, the amount covered by the third-party payer.

Answer 14

Insurance Benefit

Question 15

Average price that wholesalers sell a medication
Not regulated by government does not take into account or discount based on volume 

Answer 15

Average wholesaler price (AWP)

Question 16

Actual acquisition cost the pharmacy pay for the medication 

Answer 16

AAC plus dispensing fee 

Question 17

Financial accounts, establish by employee for basically financial accounts
family to pay for qualify medical expenses 

Answer 17

HSA . Health saving Account

Question 18

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

Answer 18

FSA

Question 19

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 

Answer 19

HSA healthcare savings account

Question 20

Cost formula=

Answer 20

Purchase price + cost to dispense

Question 21

Purchase price x discount rate

Answer 21

Discount formula

Question 22

Purchase price - discount =

Answer 22

Discount price formula

Question 23

Selling price - purchase price =

Answer 23

Gross profit

Question 24

Gross profit formula=

Answer 24

Selling price - purchase price

Question 25

Sum of all expensive =

Answer 25

Overhead

Question 26

Selling price minus overall cost =

Answer 26

Profit formula

Question 27

Average price that wholesaler sell a medication
Not regulated by government
Does not take into account discount based on volume

Answer 27

Average wholesale price (AWP

Question 28

Actual cost is the pharmacy pay for the medication formula

Answer 28

Actual acquisition cost ( ACC) + Dispensing fee

Question 29

This is used in calculating the reimbursement formulary for generic medication :
Determined by managed care organization

Answer 29

MAC + dispensing fee

Question 30

Income minus overhead

Answer 30

Net profit

Question 31

What is fee for service reimbursement?

Answer 31

Fee for service is an amount pay based on the service delivered

Question 32

What is capitation reimbursement?

Answer 32

Capitation reimbursement is a set reimbursement