Third Party Billing Survival Skills for Pharmacy Interns

1
Third Party BillingSurvival Skills for Pharmacy
Interns

• Pharmacy Practice III
• 06/02/06

2
What is meant by third party?

• Insurance
• Medicaid
• Coupons
• Drug Cards
• Sample cards
• Other programs
• MEDICARE

3
Finding Information on a Card

• Location, location, location???
• The numbers game
• Provider codes
• Group numbers
• Home plan
• ID number
• Person number
• BIN number

4
Example insurance card

• Source Example card obtained from Regence
  BlueCross BlueShield of Oregon
  http//www.or.regence.com/member/about/memberIDCar
  d.html 6/1/2006

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Some Basic Information

• Patients legal name
• Gender
• Date of birth
• Relationship

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Prior Authorization

• Medication specific -
• e.g. Cox 2 inhibitors, PPIs, Antifungals
• Tried other meds?
• Call prescriber number provided
• May take 1-2 weeks

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Rejected?

• Non-formulary
• Brand medically necessary- in prescribers
  writing
• Vacation
• Wrong days supply
• Dosage change
• Duplicate therapy
• Prescriber not recognized
• Coverage terminated

8
Insurance Fraud

• Inaccurate days supply
• Inaccurate NDC package size
• Failure to reverse charges when patient does not
  get rx

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Customer ConcernsCan we fix it?

• Change in co-pay
• Days supply
• Brand vs. generic
• Change in plan
• Coverage terminated new card?
• High co-pay cash may be cheaper
• Double coverage
• What is my co-pay?

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Manager concernsCan we afford it?

• Make sure the claim was processed
• Beware of zero co-pay
• Reimbursement less than cost

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Customer Service

• Communication skills - Empathy
• Patient education
• Assisting with high prices
• Cash may be cheaper
• Generics, other meds in class, pill splitting
• Contact prescriber
• List options, cost/month
• OTCs?
• Local resources
• Other programs

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Your Resources

• Computer software help windows
• Telephone call the PBM
• Technicians
• Value their expertise!

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Pharmacists roles

• Help patients understand the program
• Help patients choose card
• Inform patient of remainder of 600 credit
• Inform of less expensive alternative
• Pharmacies as source of discount savings?

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References

• Mellen A. The Pharmacy Students Guide to Third
  Part Billing. J Retail Pharmacy 2003 5 9-12
• Zweber A. Making the Best of a Bad Situation. J
  of Pharmacy Experience 2002 1 1-10