Commercial Payor Overview

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Carol Morris
9 years ago
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2 This information is provided d for your background education and is not intended to serve as guidance for specific coding, billing, and claims submissions. The decision on which codes best describe the services provided must be made by the individual providers based on specific payor guidance and requirements. 2

3 Agenda Review types of commercial plans Medical vs. pharmacy benefit Payment methodologies Determining primary and secondary insurance Patient cost-share Insurance verification 3

4 Types of Commercial Health Plans Health Maintenance Organization (HMO) Members see Primary Care Provider (PCP) Typically requires a referral to access specialty care Preferred Provider Organization (PPO) Members can see out-of-network providers at a higher cost Point of Service (POS) Members can self-refer or go outside the network at a higher cost Traditional Indemnity Typically no network. Members can see the physician of their choice at a higher out-of-pocket cost 4

out-of-network providers at a higher cost Point of Service (POS) Members can self-refer or go outside the network at a

5 Access Via COBRA Coverage The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) allows employees who lose their jobs to continue their employer-sponsored health insurance coverage for up to 18 months Individuals must have been enrolled in their employer s health insurance prior to being laid off or experiencing another event, such as a divorce, that would cause them to lose employer-sponsored health insurance COBRA challenges: The cost of the premium can be a significant barrier for many laid-off workers and their families Employees who lose their jobs because the employer goes out of business cannot qualify for COBRA 1. KFF Issue Brief The COBRA Subsidy for the Unemployed April Accessed June 2,

lose employer-sponsored health insurance COBRA challenges: The cost of the premium can be a significant barrier for many laid-off workers and their families Employees who lose their jobs because

6 Key Components of Health Plans Benefit design Medical Pharmacy Types of covered services Physician services Drugs or biologicals Cost-share share requirement of enrollees Co-pay vs. co-insurance 6

7 Acquisition of Physician-Administered Drugs Options for acquiring physician-administered drugs are often impacted by payor policies and plan-specific benefit design Medical Benefit Usually includes infused and injected drugs typically administered in physician offices, hospital outpatient departments or infusion centers Pharmacy Benefit More likely includes oral and selfadministered drugs 7

infused and injected drugs typically administered in physician offices, hospital outpatient

8 Medical versus Pharmacy Benefits Typically benefit coverage is driven by site of administration Medical Benefit Coverage based on policy and varies by payor Single co-pay/co-insurance for the office visit (typically no cost sharing for the medication) Systematic utilization control used selectively (ie, prior authorization, predetermination) Reimbursement based on HCPCS/CPT* code Provider bills for both the drug and administration service(s) Assignment of Benefits (AOB) option Pharmacy Benefit Af formulary (or preferred ddrug list) t)is the primary management technique Promotes use of preferred drugs Tier placement is generally determined by cost of product Treating physician not at financial risk Co-payments/co-insurance in addition to the office visit Prospective utilization management and prior authorization common Claim processed via NDC *HCPCS Healthcare Common Procedural Coding System; CPT Current Procedural Terminology NDC National Drug Code 8

for both the drug and administration service(s) Assignment of Benefits (AOB) option Pharmacy Benefit Af formulary (or preferred ddrug list) t)is the primary management technique Promotes use of

9 Payment Methodologies For Professional Services Varies based on individual payor contract For Drugs or Biologicals Buy and bill reimbursement methodology is determined by individual payor contract Physicians typically reimbursed based on a negotiated fee schedule Examples include: ASP+% AWP-% WAC+% % of billed charges ASP - Average Sales Price AWP - Average Wholesale Price WAC - Wholesale Acquisition Cost 9

Physicians typically reimbursed based on a negotiated fee schedule Examples include: ASP+% AWP-% WAC+%

10 Primary vs. Secondary Payor Some patients may have two or more sources of insurance coverage For example Medicare and Medicaid Medicare and private insurance Identification of primary vs. secondary payor should be established prior to initiating therapy Potential impact on claim submission process and patient outof-pocket costs 10

For example Medicare and Medicaid Medicare and private insurance Identification of

11 Patient Cost-Share Options Out-of-pocket costs vary by patient and are determined by individual health plan design 11

12 Insurance Verification A comprehensive patient-specific insurance verification is the first step to ensuring patient access to therapy Insurance verification helps determine: Insurance changes and updates Patient-specific coverage Benefit-design access options Patient out-of-pocket costs Amgen Assist is available to initiate the verification process 12

Insurance changes and updates Patient-specific coverage Benefit-design access options

13 Summary Every commercial insurance plan is different Completing an insurance verification prior to initiating therapy will help ensure coverage and the patient s out-of-pocket costs Even with help from a reimbursement support service such as Amgen Assist, the accuracy and appropriateness of the information included on claims remains the responsibility of the individual healthcare providers 13

from a reimbursement support service such as Amgen Assist, the accuracy and appropriateness of the

Reimbursement for Physician- Administered Drugs:

Reimbursement for Physician- Administered Drugs: Reimbursement for Physician- Purchased and Physician- Administered Drugs: Understanding the Buy and Bill Process 60889-R5-V1 This information is provided d for your background education and is not intended