Point of Sale (POS) Pharmacy Billing

Housekeeping Verify you can log into you facility Verify that you have the POS menus (if you are using POS) Verify you can print to the printer in the room

Objectives Describe the general principals of pharmacy billing. Describe processes that need to be in place to be successful at pharmacy billing List the reports are available in RPMS POS? Describe how to correct different types of rejections using the POS software.

Training Plan Reference – FTP site: ftp://ftp.ihs.gov/rpms/POS/ Understand RPMS software – POS set-up Learning business end of pharmacy billing to maximize collections Network agreements (contracts), review insurers set-up Audits, HIPAA, programming plans/projects

Point of Sale Pharmacy Billing Outpatient Pharmacy package Patient Registration package RPMS system Processor Response Point of Sale package Switch Transmission process (sending claim) versus response (from payer). NCPDP sets standards for transmissions – payers, providers (pharmacies), vendors Patient Care Component (PCC) - visit files Third Party Billing & Accounts receivable packages

Key Components to Using RPMS POS Coordinated effort: Business Office, IT, Pharmacy Best – “hire or assign pharmacy biller” Having the necessary menus/keys Network participating agreements Staying current with software patches Outpatient Pharmacy 6.0, patch 5 or Outpatient Pharmacy 7.0, patch 3 POS version 1, patch 13 AWP (APSA) and Patient Education (APSE) updates http://www.ihs.gov/Cio/RPMS/index.cfm?module=home&option=index Drug file clean-up Patient registration Terminal ID# - provide info on how to process purchase order to WebMD. To have a tribal facility added to Express Scripts contract – contact Pam Schweitzer Load the software – site manager needs to be aware of minimum software requirements. See Configuration survey handout. Pam Schweitzer can assist sites in set-up and training. Contact through outlook or ITSC Help Desk.

Pharmacy Benefit Management (PBM’s) An organization that manages pharmaceutical benefits for employers, other providers or managed care organizations Involved in: Benefit plan design, Claims processing, Formulary management, Manufacturer rebates, DUR review Examples of PBM’s: Medco Health, Caremark, Express Scripts, First Health (Coventry), Rx America

PBM Web Site See handout with links

Network Agreements Patient Insurance Card Network enrollment application Vendor Information Software vendor: Indian Health Service 5300 Homestead Rd, Albuquerque, NM 87110 Software: RPMS POS, NCPDP V5.1 Addendum Network participating agreements – first need to know main employers and primary insurance of patients seen at facility. National IHS contracts in place – First Health, Express Scripts.

Status of Agreements - IHS National Express Scripts, First Health (Mail Handlers), Medicare Drug Card (PCA, Criterion) Medco Health Medicare Part D – January 1, 2006 (several) In the works: Tricare/Express Scripts – signing process Caremark - review Aetna – review MedImpact – review Argus – signing process PCN – signing process Pharmacare - review

Outpatient Pharmacy Package SFUN / SITP / IHSP - location of POS “switch” Drug file AWP monthly updates http://www.ihs.gov/CIO/InfoTech_index.asp APSA APSE – Patient Education - quarterly Status of patches – Outpatient Pharmacy Supervisor Menu - Maintenance

Outpatient Pharmacy Package – Drug File, continued…. Mailman message – lists unmatched drugs EAWP – Outpatient 6.0 AWP Manual Update Outpatient Pharmacy v 6.0 patch 5 Outpatient Pharmacy v7.0 – new version (10/2004) – 46 sites using

AWP Manual Update Subj: Outpatient Pharmacy AWP Automatic Update [#12914] 16 Nov 04 12:21 200 Lines From: OUTPATIENT PHARMACY DEVELOPER in 'IN' basket. Page 1 **NEW** ------------------------------------------------------------------------------ An Average Wholesale Pricing update was performed on your system on 3041116. The total number of records updated = 924   Listed below are the active drugs that were not updated and the error codes. Please review and correct all errors before attempting to run the manual AWP update option. Note: any 'missing 660 node' errors means that information like Order Unit, Price Per Order Unit, Dispense Units Per Order unit, Price Per Dispense Unit, etc) is missing! ACETAZOLAMIDE 500MG INJ - DISP UNITS DON'T MATCH - Medi = 90 / Local = 1 ACYCLOVIR 200MG/5ML SUSP,ORAL - DISP UNITS DON'T MATCH - Medi = 473 / Local =480 AWP Manual update - Used by the pharmacists to clean up the drug file. 900+ records updated is “good.”

Drug AWP Edit - EAWP Select DRUG GENERIC NAME: GLYBURIDE 5MG TAB ORDER UNIT: BT// DISPENSE UNIT: TAB// DISPENSE UNITS PER ORDER UNIT: 1000// AWP PER ORDER UNIT: 825.69// AWP PER DISP UNIT is .82569 AWP EFFECTIVE DATE: JUN 5,2001// NDC: 00009-0171-07// DEA, SPECIAL HDLG: 6// LAST PRICE UPDATE: INACTIVE DATE: PRICE PER ORDER UNIT: 17.31// PRICE PER DISPENSE UNIT is 0.017 This is part of the pharmacy package – where the pharmacy updates the drug file. Critical fields for the NDC to “match,” (I.e. to the correct AWP) are: Order unit, Dispense unit, dispense units per order unit, NDC. It is highly recommended that DEA special handling be completed. “9” for OTC’s will enable you to not bill OTC’s, if so desired. There is a handout – Drug Enter/Edit – that provides detail on how to clean up the drug file.

Formats NCPDP field names/numbers – POS / RPT / OTHR Or see handout WebMD: switch company –– GSA contract - $ 0.025/transaction Information needed when adding a new insurer/format: Processor BIN number Plan name/number Processor Control Number (PCN) or carrier ID Help desk phone number Requesting a new format

Patient Registration Insurer Name Employer Group name/number Table Maintenance Person code Ideas for collecting patient registration information

POS Set-up POS / MGR / Set-up BAS Pharm INS BILL PROV SUMI

POS Menu’s Reports CLA / PAY, REJ, PAP, URM, DAY, INS Survey

Setting up an Insurer POS / MGR / SET / INS INS – RPMS insurer, POS Format (use Excel spreadsheet) ADV – assign priority points RPMS – set to P

Using POS User Menu Live Claims Payable claim to RPMS A/R package

POS Rejections How often to run reports? Need process to address them. Ideally – rejection report daily Need process to address them. Coordinated between Business office and Pharmacy See Reject codes

Rejection Handout

POS Rejections Cardholder ID, Group number, eligibility Refill too soon, NDC, Day supply, drug not covered DUR, Prior Auth, Prescription Clarification code

Resources Web Links – handout Payer Help Desk – see POS rejection report for phone number. Before calling, have claim pulled up: POS / U / EV / 3-Patient name / REC

POS Rejections DUR override: Show Rx Bill or POS / U / N 439 REASON FOR SERVICE CODE 440 PROFESSIONAL SERVICE CODE 441 RESULT OF SERVICE CODE See handout for DUR codes

Prior authorization Can be input in either of these packages: Show Rx Bill (Pharmacy package) or POS / U / N (POS package) Example Refill too soon due to dosage change: 98798798798

Backbilling Electronic limitations (# days to backbill) Prescription number POS / U / N

Troubleshooting RPMS support Network issues, changing internet providers, maintenance by payers. Taskmanager Cache conversion

Network Agreements Verify processor, patient name, employer Addendum National contracts, Regional, Facility contracts NCPDP Provider Number update

Universal Claim Form (UCF) Part of 3PB package Need to order forms: Moore North America, Inc. Moore National Customer Service Center: (800) 635-9500 For version 5.1, HIPAA compliant item # DAH2PT: 1500 forms per carton – 9 ½’’ x 11”, continuous pin feed; $56.21 per carton ($0.04 per form) + shipping

Audits Three to five years of records, payable claims – read contract to verify. Copy of Rx Hard copy readily retrievable Copy of Prior Auth (PA) Signature log

HIPAA – Pharmacy Policy and Procedures addressing the following: Privacy consultation area Staff Training on HIPAA Medication pick-up by proxy Disposal or destruction of patient drug history information Leaving information on patient’s home or work answering machines Confidentiality Forms

Wrap-Up Action plan