1. 12
Insurance and Third-Party Billing

2. State Standard
30) Compare and contrast healthcare reimbursement systems in home health, long-term care, and home infusion. Develop a technology-enhanced presentation to share information with classmates, healthcare professionals, or pharmacy staff.

3. Objectives Students will be able to…
Identify the different types of insurance reimbursement programs.
Create a presentation that compares and contrasts healthcare reimbursement systems in home health, long-term care, and home infusion.

4. Insurance Billing
Prescription insurance helps Americans defray high health care costs.
Technicians in ambulatory pharmacies process insurance claims for patients.

5. Formularies
FDA maintains national formulary of prescription medications.
Includes all approved prescription and generic drugs

6. Formularies Pharmacy formulary Pharmacy Benefit Manager (PBM)
Open formularies cover drugs not listed in the formulary
Closed formularies only cover listed drugs

7. Formularies Pharmacy formulary
Restricted formularies restrict and limit the types of drugs to generics or specific drugs within a certain class.

8. Formularies Pharmacy formulary Tier
Very particular list of prescription drugs
PMB divides formularies into tiers
Each tier associated with a certain patient payment or co-pay
Usually generic, preferred brand, and nonpreferred

9. Drug Utilization Reviews/Evaluations
Improve quality health care and patient safety; ensure formulary is used in a mandatory manner
Prior (or pre) authorization
Checking drug against formulary, patient eligibility, dosage, drug or disease interactions, and other issues

10. Drug Utilization Reviews/Evaluations
Pharmacy technician and pharmacist receive any edits or changes to Rx
Prescriber is contacted for special questions or issues.
Insurance issues cleared up
Therapeutic interchange: substituting one drug for another in the same class

11. Types of Insurance Health Maintenance Organization (HMO)
Contracted hospitals, doctors, pharmacies, and other providers
Patient selects a primary care physician (PCP) to be first point of medical care who must refer to any specialists, generally the least expensive insurance plan option

12. Types of Insurance Health Maintenance Organization (HMO)
Examples: Aetna, Cigna, Humana, Kaiser, TRICARE (CHAMPUS)

13. Types of Insurance Preferred Provider Organizations (PPO)
Patients have greater choice of health care provider than in HMO
In-network providers
Out-of-network providers

14. Types of Insurance Preferred Provider Organizations (PPO)
Patients can generally choose a specialist without a referral or prior authorization.
Examples: BlueCross/BlueShield, Pacificare, United Healthcare

15. Types of Insurance Drug discount/coupon cards
Offer a small amount off cost of prescriptions
Chain retail discount cards include pharmacy drugs and items.
Drug manufacturer vouchers and coupons
Patient Assistance Programs (PAP)
Senior discount cards

16. Types of Insurance Medicare
Government health insurance program for individuals aged 65 or older, younger people with disabilities, and people with End Stage Renal Disease (ESRD); provides hospital, medical, and prescription insurance

17. Types of Insurance Medicare Part A: hospital insurance
Part B: medical insurance
Part D: prescription drug insurance

18. Types of Insurance Medicaid
Government health insurance program for individuals and families with low incomes or members with disabilities
Eligibility requirements are determined and vary by state.
Some patients may have both Medicaid and Medicare.

19. Types of Insurance TRICARE
Medical insurance for U.S. military and their families
Department of Defense health insurance plan
All branches of the armed services, public health service, and National Oceanic and Atmospheric Administration (NOAA)

20. Types of Insurance TRICARE TRICARE Standard TRICARE Prime
Fee based; covers those who cannot obtain services from a military treatment facility (MTF); capped cost share
TRICARE Prime
Like an HMO

21. Types of Insurance TRICARE TRICARE Reserve Select TRICARE for Life
For National Guard and Reserve Activated personnel enlisted after 9/11/01
TRICARE for Life
Guarantees lifetime coverage for military personnel

22. Types of Insurance TRICARE Payment protocol Medicare pays first.
Secondary insurance pays second.
TRICARE picks up unpaid balance.

23. Types of Insurance TRICARE TRICARE Drug Programs
Prescriptions filled at network or non-network pharmacies

24. Types of Insurance CHAMPV
Civilian Health and Medical Program of the Veterans Administration (CHAMPV)
Covers families of veterans with service-related injuries or those who died in service

25. Types of Insurance CHAMPV
The Veterans Healthcare Eligibility Reform Act (1996) requires those with a 100% disability to be included in CHAMPV to be able to get health care costs covered.

26. Types of Insurance Worker's compensation
For employees who are injured at work
Patient is not responsible for any payment; all costs covered by employers.
Extensive and tedious paperwork

27. Types of Insurance Worker's compensation
Many insurance companies recruiting and hiring pharmacy technicians for their extensive knowledge of medications, insurance benefits, and the billing process

28. Activity Complete drug cards for the following…
Nitroglycerine
Oxybutynin
Tadalifil
Per st. 30, Compare and contrast healthcare reimbursement systems in home health, long-term care, and home infusion. Develop a technology-enhanced presentation to share information with classmates. Include information over...
What happens in each facility?
What population do they serve?
Which reimbursement types are seen in each location

29. Billing

30. State Standard
29) Role-play explaining the reimbursement policies and plans (e.g., HMOs, PPO, CMS, private plans) to a patient/client who has presented a prescription for three of the top 200 drugs. Ensure the accurate explanation of relevant third-party resolution issues (e.g., prior authorization, rejected claims, plan limitations)** and third-party reimbursement systems (e.g., PBM, medication assistance programs, coupons, and self-pay).

31. Objectives Students will be able to…
Identify components of the insurance billing process.
Create an educational brochure that explains each type of reimbursing program and use it to educate a simulated patient

32. Understanding the Insurance Billing Process
Most ambulatory pharmacies bill patients' insurance carriers directly.
Pharmacy technician responsible for collecting, maintaining, and transmitting claims via computer

33. Figure 12-1 The insurance billing process is usually done by computer
Figure The insurance billing process is usually done by computer. Source: Keith Brofsky/Getty Images, Inc.

34. Understanding the Insurance Billing Process
Insurance Terms
Adjudication
Process of transmitting a prescription electronically to the proper insurance company or third-party biller for approval and billing
Carrier/insurer/provider
The patient's insurance company

35. Understanding the Insurance Billing Process
Insurance Terms
Processor
Company hired by the insurer to process claims
Claim
Request for reimbursement from health care provider to insurance provider for products or services rendered

36. Understanding the Insurance Billing Process
Insurance Terms
Co-pay
Portion of cost of a service or product that patient pays out of pocket each time it is provided
Deductible
Set amount client pays up front before insurance coverage applies

37. Understanding the Insurance Billing Process
Insurance Terms
Dispense as written (DAW)
Notation by prescribers instructing pharmacy to use exact drug written (usually a brand-name drug)
Days supply
Number of days a dispensed quantity of medication will last

38. Figure 12-2 Insurance information.

39. Collecting Insurance Data
Patient profile information kept by pharmacy, insurance providers, and third-party processors.
Information gathered must match exactly that which the insurance company has on file: name, address, marital status, date of birth

40. Transmitting Prescriptions
The insurance provider will need to know:
Name of the medication being dispensed (matched against a formulary; the insurance provider will only pay for approved medications)

41. Transmitting Prescriptions
The insurance provider will need to know:
Strength and dose of medication
Whether a generic alternative is available

42. Transmitting Prescriptions
Insurance provider will not pay for brand-name drugs unless physician places “DAW” (Dispense As Written) on prescription
DAW codes 0, 1, and 2 signify physician’s authorization of brand-name or generic drug
DAW code errors by technician can result in charge of insurance fraud.

43. Figure There are times when an insurance issue cannot be handled by computers. Source: Minerva Studio/Shutterstock

44. Troubleshooting Insurance
Common errors/messages can result in insurance billing rejections.
Technician may have to call the insurance company and explain the issue.
Insurance billing is a customer service.
Computers only work as well as the people operating them.

45. Fraud
Healthcare Fraud and Abuse Control Program (under HIPAA) catches and prosecutes fraud and abuse in health care and insurance claims.
Office of Inspector General enforces related laws.

46. Fraud FBI and Dept. of Justice also involved
Federal False Claims Act and USC 3729 prohibit submitting fraudulent claims and making false statements in conjunction with claims

47. Fraud Laws against insurance fraud in various forms include:
Federal False Claims Act and USC 3729
Anti-kickback statute
Stark
Sarbanes–Oxley Act of 2002
State false-claims statutes

48. Billing
Price changes happen often and must be updated in computer database.
Pricing systems are pharmacy-specific.
Allow pricing to be updated

49. Billing Pricing systems are pharmacy-specific. Features include:
Increased billing speed and accuracy
Paperless file management
Better customer service
User friendly programs
Training manuals or training from a program specialist
Fewer medication errors

50. Information Systems Pharmacy system should support:
Inpatient order entry, management, and dispensing
Outpatient order entry
Management and dispensing
Inventory and purchasing management
Reports of utilization, workload, and financial reports

51. Information Systems Pharmacy system should support:
Clinical monitoring
Manufacturing and compounding
Intervention management
Medication administration
Connectivity to other systems
Pricing, charging, and billing

52. Information Systems Pharmacy system monitors clinical issues such as:
Drug interaction allergies
Food interactions
Lab test interactions
Dosing
Disease state side effects

53. Information Systems Price updates
Computerized information management systems offer automatic pricing and updates for changing inventory quantity and prices.

54. Information Systems Price updates
Or updates can be completed using data entry software and organization, with final results transferred to spread sheet programs for review
Billing programs vary between institutional and retail settings.

55. Information Systems Report generation
Various programs store, compile, and print data based on information entry.
Pharmacy technicians complete data entry.

56. Information Systems Report generation
Data imported to spread sheet and reviewed or printed
These reports aid decision making for ordering products and supplies, and show financial gains and losses for the pharmacy.

57. Activity Complete drug cards for the following… Triamcinolone
Levetiracetam
Lansoprazole
Per St. 29, you will be creating an education brochure over the different types of insurance reimbursement seen in Pharmacy practice. You need to explain each in terms that an elderly person would understand. Place your information in a visually appealing brochure that could be used on the front desk of a pharmacy counter to educate patients.
Once finished take turns explain a least 1 reimbursement type to a partner.

58. Summary
Insurance billing requires a comprehensive knowledge of billing terms, codes, and policies, such as DAW codes, authorized days supply, and formularies.
Properly trained pharmacy technicians can assist the pharmacist by handling these responsibilities.