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.

•copayment--pt pays % of med or x amount and ins co pays rest.

•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 physicianIPA--independent physician associationcapitation-- 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 deductiblebefore 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 facilityMedicare part B--helps pay physican and outpatient care, equipment (DME), pays OT,PTMedicare part C--(medicare advantge)=BUY HMO/PPO privateins to help with medicare A and B

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 madeDAW1= use brand nameDAW2= dr recommends generic, pt wants brand nameDAW3—dr wants generic, Dpharm request brand name

Medicare part D---(rx drug plan)= pt pays this to get discountsmeds, vaccines, supplies. problem is it pay a maximum $ then stops payment(aka donut hole). you can pay for Medigapins 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.

NPI--national provider identifier- every dr and pharmacy for billing

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

TRICARE---for military and familyCHAMPVA--- civilian health and medical program/ veteran affairs for disabled veterans and familypt cannot have tricare and champva--pick oneshow ins cards------Premium=the cost to get your insuranceSubscriber=cardholder. Dependants on the policy. Member=1 spouse=2 id=3Health savings account=account to pay for medical expenses.

how do we get paid???--fill out a UCF( universal claim form)

pt drug not on formulary? dpharm calls dr to get rx changed ordr 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 findTherapeutic equivalent on the list.

limitation of plan exceeded---pt pays or pt can call ins co.

somebody gotta pay

markup+dispensing fee=pt costdispensing fee=monthly cost/rx per monthIns co will usually pay dispensing feeAWP+- (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)

Ins card---BIN= 6 digits on biller ID numberPCN=processor control numberCoordination of benefits—for multiple insurance. Secondary ins pays if primary does not pay.