pharm get paid! adjudication---’dealing’ with ins to get paid max allowable cost--max price ins co will pay for generic capitation fee- pharm gets paid x per pt per month, whether or not they come in. deductible--ins co pays nothing until pt pays x amount for medical services. Out of pocket=you pay for it Premium---your cost to have insurance copayment--pt pays x amount and ins co pays rest. Coinsurance---pt pays % of the visit AWP--average wholesale price. found in ‘red book’. used for ins reimbursement(payment)
3rd party plans • HMO health maintenance organization---providers sign contract and must follow HMO orders, wont pay outside network unless referral. prov under contract. pt must choose PCP on the list. PCP must give referral if outside network. • PPO preferred provider organization---providers contract with ppo. ins pays less if you go outside PPO. • POS point of sale---sending ins claims electronically • medicare----federal program for over 65? or disabled or kidney failure. • medicaid----federal program administered by states who determine services and entry. not all drugs paid for. • pt assistance program---drug maker offers assistance for special needs and affordability. • work comp---on the job injury. rx billed to ins co.
PCP= primary care physician IPA--independent physician association capitation-- ins pays dr per pt whether show up or not. HMO--pt must go to PCP or IPA on list. pt pays copay. prior authorization-(pre-auth)--no payment for x treatment or drug until ins approves. PPO- preferred provider organization. pt can pick dr on list or any specialist on list. copay is higher. pt must pay deductible before benefits kick in. dr agrees to discount to be on list. Point of service---combo of HMO and PPO. MMA=medicare modernization act--you get rx drug discount drug. Medicare part A---helps pay hospice, hospital, skilled nursing facility Medicare part B--helps pay physican and outpatient care, equipment (DME), chemo drugs, pays OT,PT Medicare part C--(medicare advantge)=BUY HMO/PPO private ins to help with medicare A and B
Medicare part D---(rx drug plan)= pt pays this to get discounts meds, vaccines, supplies. problem is it pay a maximum $ then stops payment(aka donut hole). you can pay for Medigap ins c private ins. Medicare SELECT means pt must go to hosp/dr on list to have no fee. if you have medicare part C then you are denied Medigap. medicaid--poor or renal failure. fed and state pay it. state can set requirements. coverage is 1--pt pays nothing. 2--pay deductible 3--HMO c govt NPI--national provider identifier- every dr and pharmacy for billing DUR/DUE--drug utilization review. alert of dangerous drug ..or ‘fighting’ over medication for pt c ins. DAW 0= give generic unless there is no generic made DAW1= use brand name DAW2= dr recommends generic, pt wants brand name DAW3—dr wants generic, Dpharm request brand name
TRICARE---for military and family CHAMPVA--- civilian health and medical program/ veteran affairs for disabled veterans and family pt cannot have tricare and champva--pick one show ins cards------ Premium=the cost to get your insurance Subscriber=cardholder. Dependants on the policy. Member=1 spouse=2 id=3 Health savings account=account to pay for medical expenses. pt drug not on formulary? dpharm calls dr to get rx changed or dr calls ins co to get preauth for nonformulary drug. this fight may take several days so pt can get reimbursed later or wait for approval. Therapeutic interchange protocol—closed formulary but will find Therapeutic equivalent on the list. limitation of plan exceeded---pt pays or pt can call ins co. how do we get paid???--fill out a UCF( universal claim form)
somebody gotta pay markup+dispensing fee=pt cost dispensing fee=monthly cost/rx per month Ins co will usually pay dispensing fee AWP+- (AWPx%)+disp fee=pt cost Purchase order goes to vendor who makes invoice. Verify invoice and purchase order when drugs get delivered. Prime vendor=pharmacies main wholesaler(80-85% of needs) with likely discount Ins card--- BIN= 6 digits on biller ID number PCN=processor control number Coordination of benefits—for multiple insurance. Secondary ins pays if primary does not pay.