Third Party Payments Flashcards
AWP
Average Wholesale Price
An average price that wholesalers charge the pharmacy for a given drug, dose, and package size.
prescription reimbursement
AWP + percentage + dispensing fee
health insurance
coverage of incurred medical costs such as physician visits, laboratory costs, and hospitalization.
PBM
pharmacy benefits manager
a company that provides such service by administering the prescription drug benefits and pharmacy reimbursements for insurance companies
deductible
an amount that must be paid by the insured before the insurance company will consider paying its portion
annual deductible is commonly between $100 and $3000 and starts with beginning of new calander or fiscal year depending on the company
co-payment
the flat amount that the patient is to pay for each prescription
co-pays vary by both drug (generic vs. brand) and insurance company
coinsurance
a percentage-based plan in which the patient must pay a certain percentage of the prescription price
not a common as the deductible and co-pay plans
private insurance
most patients have private insurance either through their employer during their wage-earning years, or as a retiree of large company
HMO
health maintenance option
lower costs out of pocket for patient however not all providers or pharmacies are covered and the preferred drug list is commonly restriced to generic drugs
dual co-pay
one co-pay for brand name drugs and a lower co-pay for generic drugs
tiered co-pay
has an escalating cost for a generic, a pereferred brand, and a nonpreferred brand
PDL
preferred drug list
medicaid
subsidizes the cost of health care, including drugs, for indigent and disabled citizens of each state who meet age and income eligibility requirements
usual and customary charges
this term means that the pharmacy cannot charge the state more for the same prescription dispensed to a patient with private insurance.
tricare
is a federal health and prescription drug insurance plan that is available to active and retired members of the military and their families
medicare
once a patient is aged 65, he or she is eligible for medicare
medicare does not cover prescription drugs and patients require additional coverage or supplimental insurance for physician visits and prescriptions
Medicare Advantage
also known as Medicare Part C
combination of both health and prescription insurance from the same provider
Medicare Part D
the Medicare Prescription Drug, Inprovement, and Modernization Act (MMA) of 2003 - commonly called Medicare Part D
gives eligable patients the option to add prescription drug insurance to their existing medical coverage for an additional cost.
worker’s compensation
provided insurance to cover medical care and compensation for an employee who is injured in the course of employment, in exchange for a waiver of the employee’s right to sue his or her employer
COB
coordination of benefits
processing a claim through both a primary and secondary insurer
these patients are called “dual eligible”
uninsured
commonly due to no employment or underemployment
prescribers and pharmacies should work together to identify the most common low-cost generic prescription for the required disease or illness
some pharmacies may advertise a list of “free” or low-cost ($4) prescriptions.
“loss leaders”
low priced ($4) medication lists advertised by companies
the retailer may choose to lose or break even on drug costs if the lowered preices entice consumers to visit the store and buy more groceries or merchandise
drug discount cards and coupons
a benefit to uninsured patients and others
some pharmacies offer a prescription savings club card
other patients will present a drug discount card or coupon
terms of such cards must be carefully reviewd. some do not offer any discount if an insurance claim is made
BIN
bank identification number
online adjudication
refers to using wireless communications to process prescription claims for private insurance, medicaid and medicare part D
days’ supply
the time that a given amount of medication lasts
prior authorization
when a medication is not covered by drug insurance, or when the prescirber decided that the patient must have a medication that is not on the PBM’s formulary, the prescriber’s nurse may have to call the PBM to obtain a prior authorization for the prescription to be covered properly
insurance fraud
filing a false claim
medication cannot be dispensed to a patient and then the insurance company billed thre days later
the patient must return in three days to pick up the medicaiton once the insurance has been billed
audits
a pharmacy is subject to medication audits from any insurer.
an audit is a challenge on a reimbursement form a PBM or insurance provider on a prescription claim that has been previously processed.
can be from processed precriptions from 3-6 months prior
charge back
is a rejection of a prescription claim by a PBM or insurance provider that must be investigated and, if possible, resolved by the pharmacy technician.
closed formulary
a system in which specific drugs in each therapeutic class are covered.
drugs that are not listed are either not covered at all or require prior authorization
dependents
the spouse or children covered under an employee’s insurance policy
disease management (DM)
a program of preventative, diagnostic and therapeutic measures intended to provide cost-effective quality healthcare for a patient population suffering from or at risk for specific chronic illnesses or diseases
drug utilization review (DUR)
a program that evaluates the safe, effective, and appropriate use of prescribed drugs
eligibility
the confirmation that the patient has coverage under a specified insurance plan
exclusive provider organization (EPO)
a healthcare benefit arrangement similar to a PPO, but with out-of-network coverage
fee schedule
the fee set by a managed care program to be acceptable for a procedure or service, which the provider agrees to accept as payment in full
formulary
a listing of drugs that are considered preferred therapy by a managed care program. The drugs listed are predeterminded to be the best medications for cost by the program
generic substitution
dispensing a drug that’s the generic equivalent of a drug listed on a PBM plan formulary. In some states this can be done without physican approval
health information network (HIN)
a computerized system that links healthcare entities to exchange patient, clinical, and financial information in an effort to provide quality health care and reduce costs
override
considered to be an exception to the rule. common examble is a patient requesting a refill too soon because they are leaving for vacation. the pharmacy may then call the insurance company and obtain a vaction override to the rule that prevents refilling a medication too soon.
step therapy
certain costly drugs are covered only if less expensive, preferred alternatives have already been tried
