PHARMACY BILLING CYCLE Prescription Filling Process Claims/Transactions Process Patient Payment Process/Point of Service GAP ANALYSIS

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1 PHARMACY BILLING CYCLE Prescription Filling Process s/transactions Process Payment Process/Point of Service Prescription Intake Order Entry and Verification Generated Transmitted Switch Vendor REVIEW PBM Adjudi cation CONTACT PBM Pharmacy CONTACT PBM Contact or Prescriber Pays Cash END ACCEPTED Pharmacy Filling and Recording of Dispensed Prescription Collect Payment from Counseling GAP ANALYSIS Gap: Clinical documentation Challenge: Need standard structured documentation templates to record, receive, and transmit patient information electronically Solution: CCDA Certified EHR Gap: Coding and claims submission Challenge: Need to use industry standards to code and submit claims Solution: Clearinghouse; Billing Service Gap: Different adjudicator Challenge: Need to understand contract requirements and medical necessity standards Solution: Clearinghouse Gap: Provider payment determined after service is provided Challenge: Need to track claims, review denials, and ensure payments Solution: Revenue Cycle; Practice Management Gap: Payment collection Challenge: Need to follow up with patients to collect payments Solution: Revenue Cycle; Practice Management MEDICAL BILLING CYCLE Care Process s/transactions Process Payment Process/Invoicing Pre-Visit and Visit Care Documentation Generated Billing Service Clearinghouse Vendor Plan Adjud ication REMITTANCE ACCEPTED Pharmacist YES Bill? NO END YES 1 EOB SENT Pay? NO

2 STANDARD FEATURES Pharmacy Dispensing Software Clearinghouse Billing Service Practice Management and/or Revenue Cycle Electronic Health Record Order entry E-prescribing (receiving) Dispensing Medication reconciliation Inventory management Point of Service system Integration with: -Electronic Health Record -Computerized physican order entry -Barcode technology for medication administration s compliance Secure transmission to payers Coding compliance Scheduling and Appointment registration and managment Billing, claim, and remittance management billing and collection Report and Analysis portal and engagement Scheduling and Appointment registration and managment Charting and maintaining medical record Internal clincial notes and External notes and Laboratory and imaging E-prescribing (sending) Workforce workflow Billing, claim management, and remittance billing and collection Meaningful Use Certificate portal and engagement 2

3 Order Entry Process 1. Collect: a. Prescription Origin Codes b. contact information c. medication, history, and disease information d. Prescriber s information e. Prescription information f. Drug Information g. Dispense as Written Codes 2. Complete Drug Utilization Review PHARMACY BILLING DOCUMENTATION PROCESS s and Transactions Process 1. Verify insurance in real-time a. Eligibility b. Co-insurance/co-pays c. Deductibles d. Benefit caps e. address f. Formulary 2. Submit claims 3. Near real-time claims adjudication MEDICAL BILLING DOCUMENTATION PROCESS Fill Prescription and Point of Service Approved Payment 1. Proper filing, checking, and recording of dispensed prescription 2. Collecting patient payment 3. Counsel patient on medication Denied Payment 1. Contact PBM to resolve denial of claim; begin prior authorization process 2. Contact patient and prescriber 3. can opt to pay out of pocket Pre-Visit and Visit 1. history, prescriptions & demographics 2. Verify insurance in real-time a. Eligibility b. Co-insurance/co-pays c. Deductibles d. Benefit caps e. address 3. Revenue cycle management: a. Verify patient address and obtain permission to contact for bill delivery b. Provide real-time out of pocket cost estimation c. Collect co-pays upfront and deductibles if possible d. Obtain credit card with approval to charge up to a define amount per coinsurance and deductibles 4. Obtain additional, (referral, prior authorization and other approvals, if needed 5. Obtain balance billing document Care 1. Collect: reason for encounter; medical and medication history; physical assessments findings; and lifestyle habits; & diagnostic test results 2. Clinical assess: health and functional status; medication adherence, and appropriateness, effectiveness; & immunizations 3. Plan: develop evidence based treatment plan; establish goals to achieve clinical outcomes; educate patient; and follow up as appropriate 4. Implement: initiate, modify, or discontinue medication therapy; provide self-management and education training; and schedule additional appointments as needed 5. Follow-up: monitor and modify plan of care as needed; ensure clinical outcomes are consistent with treatment objectives s and Transactions Process Post Service 1. Coding and charge entry by collecting and verifying: a. information and unique identifier b. Insurance information (name, address, identifier code) c. Diagnosis and procedure codes (ICD 10/CPT) d. Date and place of service e. National Provider Identifier (NPI) 2. checking and error resolution a. Ensure appropriate details in medical record to justify code & severity 3. Check the insurers payer sheet or companion guide 4. Submit claims Post Transmission 5. Check status daily 6. Resolve denials (common denials: wrong insurance, no prior authorization submitted or additional clinical documentation needed to justify severity) 7. Resubmit claim with right insurance, prior authorization number or CCD attached Post Payment 8. Verify deposits & match 835 remittances with contract agreement 9. Reconcile co-insurance & co-payments 10. Reconcile withholdings, offsets, and credit balance forwards due to prior overpayment or adjustment on another claim 11. Bill patient for payments, deductible (if not collected upfront) and co-insurance, if applies 3 Invoicing 1. Review and determine contract limitations and restrictions on amounts and services patients can be billed 2. follow up 3. Provide printed copies of Billing Policy to patients when setting up payments for deferred billing process 4. Corrective actions for non-payments 5. Collection

4 Continuity of Care Document (CCD) Clinical, demographic, and administrative patient information Advance Directives Encounters Functional Status Medical Equipment Payers Consultation Results from a provider s request for opinion or advice from another provider History of Present Illness Reason for Visit OR Reason for Referral General Status CONSOLIDATED CLINICAL DOCUMENT ARCHITECTURE (C-CDA) TEMPLATES 1 Diagnostic Imaging Report Discharge Summary information for continuation of care after discharge History of Present Illness Reason for Visit OR Reason for Referral Discharge Diet Functional Status History and Physical Medical report of patient s current and past conditions General Status Reason for Visit Instructions Operative Procedure Broad, encompassing patient s non-operative procedures Complications Post-procedure Diagnosis Procedure Description Procedure Indications Anesthesia History of Present Illness Medical (General) History Administered Physical Exam Planned Procedure Procedure Disposition Procedure Estimated Blood Loss Procedure Findings Procedure Implants Procedure Specimens Taken Reason for Visit Progress s clinical status during an outpatient visit or hospitalization Interventions Instructions Objective Subjective Unstructured Documentation 1. HL7 Implementation Guides for CDA Release 2: IHE Health Story Consolidation, DSTU Release US Realm, pp 80-83, July

5 EXAMPLES Service Transition of Care 2 Pharmacist Care Note 2 Description Documenting care provided before a patient transitions between practice settings: administered/dispensed ordered at transfer Medication reconciliation Laboratory tests results and orders instructions and counseling Clinical status Documenting counseling services including, but not limited to: Medication use Possible side effects Dietary considerations Clinical indications CCDA Template Continuity of Care Document (CCD) Progress Note : : : active and relevant history : Clinician s impressions and diagnoses : current medications and pertinent history : Pertinent current and historical clinical problems related to transition of care : care including orders, referrals, interventions, encounters, & procedures Include: : Active and relevant history : History of settings only) procedures (inpatient : Active and pertinent history and current medications CCDA Sections : Document test results and observations Include: Encounter: lists encounters or interactions Functional Status: patient s level of awareness, capabilities, and resources Immunization: current and pertinent history Medical Equipment: medical equipment and durable : medication action plan and pharmacist related care. Objective: Tests, measures and observations. : examination observations : List of relevant clinical problems : Test results and observations : s symptoms Subjective: Current conditions, response to progress of treatment, and change in treatment : Vital signs collected as part of a treatment plan 2. Recommendations for Use of the HL7 Consolidated CDA Templates for Pharmacy, Version 1.0, NCPDP, March

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