Simplify Your Workflow with Pharmacy Bill Format for Operations

Pharmacy bill format for Operations

hi what's up my friends this is your pharmacist sidra and i'm here with another lesson on pharmacy technician study guide so as a pharmacy technician your main task is not only helping pharmacists with insurance billing but you're also going to be tested on the exam about insurance billing this is something you don't want to overlook you should be a pro and expert in insurance billings because let's be honest pharmacists don't know about insurance billing we are not trained in this aspect you are the experts in insurance billing so in this video i'm gonna give you a quick overview of some of the common insurances and health insurance plans health insurance in general we know is very expensive in u.s and therefore pretty much everybody has insurances and you should be able to work with the insurances to help the patient out now before i jump into different insurance plans you have to understand what are formularies now formularies are basically the list of the medications which are approved by the insurance that they're that they're going to cover it for patient right they're going to pay for the patient often any medication out of that formulary would not be covered or even if it's covered is going to have a high copay the fda which is the food drug administration kind of maintains or keeps the national formality of the medications but every insurance pretty much have their own basic formulary list in order to get the list of the formulary given by fda you can simply go on this website which is medicinenet.com there are different kinds of formularies there is an open formulary and closed formally open formulary covers the drugs which are not listed in the list of the formulary and the closed formulary is opposite of this it covers only those medications or those specific medications which are given in the list another important term that you have to understand is tear there are three tiered formularies tier one tier two and tier three normally tier one medications are basic very generic very cost effective pretty much all the insurances will pay for it and in comparison tier 3 drugs are very expensive commonly your brand names which are high dollar amounts so insurance will sometimes not pay for it and if they pay for it they would require additional information or prior authorization from the doctor's office prior authorization is basically submitting additional information or medical justification to insurance for by a certain high dollar amount or certain brand of the medication is needed so once the doctor's office provide that additional information to insurance insurance will review it and then they will consider paying for the medication compounding medications are normally an exception to pretty much all the formularies they do not pay for compounding medications compounding medications are basically unique medications that we make individually for a certain patient keeping in mind needs of that patient so these are like unique medications not generally available uh in the market and are not manufactured by the pharmaceutical industry as a bulk so when we are making it in a small amount especially specifically for a certain patient it is going to have more cost value to it and a lot of insurances will not pay for it now in the pharmacy when a pharmacist is performing drug utilization review which is dur that's when the pharmacist will actually look at the medication and see if the medication is covered on the insurance if it's not covered is there a therapeutic equivalent that a pharmacist can recommend doctor to change to because because one probably the medication prescribed is not covered by the insurance or it is covered but has a higher copay because it's not a commonly used medication so in that case pharmacists would recommend a therapeutic equivalent which is more affordable is more cost effective but has pretty much the same effect as the prescribed medication but keep in mind we as a pharmacist cannot change the therapeutic equivalent a drug on our own we have to get prescribers approval for it so normally if a medication is not covered on the insurance we will fax the doctor either recommending them a change in the medication or we will simply request them to do a prior authorization meaning provide additional information to insurance so insurance would consider paying for it all right now let's talk about the types of insurances the first type is health maintenance organizations which is an hmo plan hmo plan is a very restricted plan like a patient it has to select a particular primary care physician they have limited selection of pharmacies where they can go to and should they need to see a specialist then the primary care provider should send the referral to a specialist they cannot just go make an appointment with a specialist on their own this plan includes insurances like kaiser aetna cigna this is a basic plan very restricted so of course this plan is going to be low cost and specifically designed for low income population in which they don't have to pay a lot for the plan annually but of course their services are limited next is the preferred provider organization this is a ppo plan this land provides greater choice to the consumer like we can select our own provider like we can go to a pharmacy of our choice or we can also go to a specialist without getting referral from a pcp we can also go to an out-of-network provider or pharmacy the only caveat to this is that should we go to an out-of-network provider or pharmacy we'll probably end up paying a little bit higher copay compared to if you go to an in-network provider but still there is an option if we have a particular provider that we like to go to we have the liberty to go to that provider but whatever copay that we pay um to that provider or pharmacy is going to go towards a deductible so that's pretty good because that amount is going to help us pay our out-of-pocket deductible the ppo plan includes mostly private insurances like united health and blue cross blue shield then we also have discount cards and discount coupons now this is an option available for someone who does not have insurance coupons are widely available online so we can simply go on google and search for a discount coupon often these discount coupons are specific to medication in specific pharmacy like they're going to say that if you get less in april and you go to walgreens cvs same art you're going to end up paying this much copay so that also helps patients save a lot of money in addition to these discount coupons several pharmacies also offer their internal discount coupons or discount plans that really helps patients save some money medicare is the health insurance for 65 years and over adults with disabilities and those who have end stage renal disease medicare is funded by federal government and medicare has different types like medicare part a covers hospital bill medicare part b covers medical supplies like test strips diabetic supplies and it also pays for insulin pumps and transplant medications then we have medicare part d which covers for prescription medications and then we have immune mpb which basically pays for flu shots and pneumonia shots medicare also has a medicare part b discount card for those who don't have medicare part d which basically pays for the prescription medications then we have medicaid medicaid insurance plan is basically for those who have low income or individuals with disabilities an example of this plan would be medical often people would have medicare and medical and that combined would be called medimedi and just like medicare medicaid is funded by state and federal government another very important and common plan that you will see in pharmacy would be tricare tricare is the plan for for u.s uniformed military service men or service women this plan include different types like tricare standard tricare for life tricare prime tricare reserve select all right another very important plan is medical which is california medical this is a state-funded plan this plan again is for low income people this plan basically has three different categories straight medical california health and wellness and anthem blue cross or medical now starting january 1st 2021 all of these different entities are going to be collected as one straight medical so we're not going to have anthem blue cross or california health and wellness with straight medical there are certain limitations they allow only six prescriptions a month but if anybody needs more than six prescriptions then we're gonna have to send a tar which is like sending additional information or documentation to medical justifying the need of the medication so we get the diagnosis information which is icd-10 code from the doctor's office we submit that on the medical website medical takes about 24 to 48 hours to review it and once reviewed they will approve or disapprove it or defer it in that case we will need to provide additional information all right so that's a little bit about the insurance plans next up i want to talk about the insurance rejections there are different third-party rejections that you're gonna get and you have to be able to identify and resolve them because that's where your expertise will fall into place all right so the first type of rejection i wanna talk about is the age limit restriction so often there are some certain medications which if used under the age of 18 or 17 could have potentially toxic or adverse reactions to the patient uh for instance codeine so in that case in anybody under 17 or 18 years old is prescribed any such medication then it is going to be rejected if you see such rejection do let the pharmacist know so the pharmacist can evaluate the prescription may contact the doctor if needed to get the pro to get the necessary diagnosis information and then based on um his or her judgment can decide to dispense the medication or not dispense the medication because in that case pharmacist professional judgment thinks that it is not safe to dispense the medication then we have the invalid birthday rejection now the birthday of the patient must always match with the birthday on insurance record if there is any mistake in the data entry in the insurance record or pharmacy record then the claim wouldn't go through patients birthday in pharmacy record should always match the insurance record and then we have the rejection for invalid person code now there are three uh basic different person codes zero when any individual is the primary plan holder let's say if a spouse is on the insurer's plan then that would be a person code 0-2 and similarly if children are on the insurer's plan then that would be code 0-3 if the appropriate goals are not selected based on the relation and birthday of the patient then you will get an insurance rejection so make sure if it's a spouse or children then make sure you link the insurer's profile to the spouse or children profile to ensure that the claim goes through the insurance refill too soon rejection now often the insurances do pay for the prescription about a week or five days ahead but if we try to fill the prescription more than five days or seven days ahead you will get a refill too soon rejection in that case do let the pharmacist know because then pharmacist is going to make judgment whether to dispense the medication or not like if a patient is going on vacation and needs an early refill then yes pharmacists will approve it often in case of control medications these are closely monitored by the pharmacist because often they are released on a 30-day cycle so anytime if you have a refill too soon rejection address that to the pharmacist so the pharmacist can proceed ingly refills not covered now this is another very common rejection in which certain health insurances require patients to refill their medications through a mail order pharmacy so at the pharmacy or at the retail community pharmacy they will apply a certain number of fills and after that they will reject saying that the patient has to go to a mail order pharmacy now some insurances offer patients to opt out of that option so a patient can simply call the insurance let them know that no i want to opt out of the mail order i want to stick with my community pharmacy but some insurances on the other hand would force patient to go through a mail order pharmacy and that's mainly for the maintenance medications not for the medications for acute treatment invalid day supply is a very important rejection when you are typing a prescription you have to make sure that you are typing the right number of days supply you should not underestimate or overestimate the day supply because if you underestimate you may get charged back like let's say if a prescription is for 30 days supply based on the directions on the medication and you type it for 20 days supply or 15 day supply the insurance may send you a charge back which means they refuse to pay for the medication because the number of days supply is incorrect and another instant would be when you overestimate the day supply for instance if a medication is for 30-day supply but you put in 45-day supply now the patient is going to run out of the medication in 30 days but since you put the 45-day supply patient won't be able to get their medication five days before the 45 days right so that would be an inconvenience for the patient and is also considered insurance fraud so make sure whenever you type in the day supply that is accurate if you are ever confused talk to your pharmacist and put in the right day supply dispensing codes now most insurances have option between dispensing name brand or the generic brand if a certain medication has generic and the insurance most likely primarily pays for the generic then that's what you should type in unless the doctor or patient specifically asks for it and if the doctor specifically asked for a certain brand then that would be your daw1 code which means that the prescriber suggested or requested a certain brand and if you put in that code then the insurance will pay for the name brand but if a patient receives the name brand when a generic is available then the patient has to pay a higher co-pay so in that case you have to let the patient know that a generic substitute is available because if you don't then that's also considered an insurance fraud and because of that patient has to pay the extra amount there are other dispensing codes as well like daw2 which is one patient requested brand daw3 which is pharmacist selected a certain brand and then we have other corresponding dispensing codes always use these codes appropriately because otherwise patient may end up paying more money for the medication and is also considered insurance fraud lastly when sometimes insurance claims are rejected it will give you the rejection reason in the computer like refills not covered use a different ndc max refills and reach things like that but sometimes you will need to call the insurance company to resolve the insurance rejection okay so lastly i want to talk about the workers comp workers comp or workers compensation is the kind of insurance which pays for an employer's injury so if anybody brings in a prescription and says that it is a worker's comp then you must verify that with the doctor's office first after you have verified you have to get additional information from the patient to submit the claim it requires a tale of paperwork it is not easy like you will need patients date of injury the place of injury the employer's name what's the location of the employers things like that once you get all that information you submit it with the workers compensation department and they review it sometimes they will approve it right away but sometimes it does require 24 to 48 hours to get it approved so in that case it's very important that you be open and upfront with the patient let the patient know if there is any rejection in how long it may take for the medication to get approved all right so that's a quick overview about the insurances and third-party rejections this is just the theoretical knowledge for you you will get the main experience and knowledge only when you practice insurance working in the pharmacy but this overview should be enough to get you started in the pharmacy if you guys have any questions please feel free to ask in the comment section or dm me and i'll see you guys next time with another video on pharmacy tech lessons study guide