Third party Financial Issues
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Third party Financial Issues

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Third party Financial Issues Third party Financial Issues Presentation Transcript

  • Third Party Financial Issues An Overview of Managed Care With a Dash of Humor
  • Your company's new health plan will cover your heart surgery but changes in your co-pay mean we take your liver.
  • What exactly is health insurance?
    • A program that helps its members obtain the healthcare services they need by reducing the risks of financial exposure
    • Risks are minimized by spreading financial costs and risks over a large group of members in the plan.
  • Overview of Rx Drug Benefits: Balancing Costs and Access
    • Health Maintenance Organization Act of 1973
      • Addresses Rising Healthcare Costs
      • Defined HMO Federal Requirements
      • Led to proliferation of HMO’s
    • Medicare Rx Drug Improvement & Modernization Act
  • Forces Driving Drug Costs
    • Utilization
      • Aging population
      • New medical treatment guidelines
        • Aggressive use
      • Available new expensive treatments
        • Demand
        • Quality of life
      • Specialty pharmaceuticals
  •  
  • The Payers and the Players
    • Health Plans
      • Indemnity or Fee for Service
    • Managed Care
      • HMO, PPO
      • Pharmacy Benefit Managers (PBM)
    • Public Health Insurance
      • Medicare
      • Medicaid
        • Medi-Cal
          • Tars/E-Tars
        • CCS-California Child Services
  • Payers and Players cont.
    • Employer
      • Premiums
    • Employee (Subscriber)
      • Dependants
      • Deductible
      • Out of Pocket Costs
      • Co-pay versus Coinsurance
  •  
  • Formularies: Clinical and Cost Containment Perspective
    • Formulary
      • Open
      • Closed
      • Limited
    • Multi-tiered Benefit Design
        • Single tier
        • Two-tier
        • Three-tier
        • Four-tier
  • More Rx Cost Containment Tools
    • Prior Authorizations (PA)
    • Step therapy
    • Supply limit
    • Refill to soon rejection
    • Drug Utilization Review (DUR)
    • Great differences between copay tiers
    • Mail order service
  • Pharmacy Impact 85-90% of prescriptions ‘touched’
    • Customer Service
      • Explaining benefit issues
      • Empathy & communication
    • Patient education & managing expectations
    • Third Party Processing
      • Eligibility Issues
      • EDS
      • NDC not covered
      • DAW
    • Common
      • Rejections
      • Top 10 3 rd party
  • Computer & 3 rd Party
    • On-line adjucation
    • Dispense as Written (DAW)
      • 0 no DAW
      • 1 md requested brand
      • 2 pt requested brand
      • 3 rph selected brand
      • 4 generic not in stock
      • 5 brand dispensed but priced as generic
      • 6 n/a
      • 7 substitution not allowed, brand mandated by law
      • 8 generic not available
  •  
  • Economics Incentive Programs
    • Pharmacy Reimbursement
      • Contracted rates
      • Payment terms
    • Increasing Generic Dispensing
    • Formulary Compliance
    • Customer Service Surveys
    • Cognitive Services
    • Wellness Programs
  • MEDICAL (California)
    • Eligibility
    • Treatment Authorizations Requests (TARs)
      • Etars
    • ID numbers
    • Date of Issue
  • Medical Cards
  • Medicare Rx Drug Benefit
    • What is it?
    • Who is it for?
    • When does it begin?
    • Which is the best plan for me?
    • New Challenges and Confusions
    • Where is the information?
    • Standard Benefit
    • Average $30/mo
    • Drug Formularies
    • Tiered Co-pays
    • Prior Authorizations
  • Medicare Rx Resources
    • www.medicare.gov
      • Select ‘Prescription Drug & Other Assistance’
      • 1-800-MEDICARE
    • www.RxSavingsAccess.com
      • 1-800-CARD4RX
    • www.Together-Rx.com
      • 1-800-865-7211
  •