Shaymous Juhnke
Third Party Processing
Third party processing is a process that all community pharmacies need to do in order to get paid through insurance. The exact process of how the claims get processes may be different from pharmacy to pharmacy, but as a whole the process is similar. For my IPPE my location was at CVS in a Target store. The first thing that happens is that the prescription comes into the pharmacy. This can either be through fax, e-script, phone, transfer, or physical copy. After the information about the prescription is entered in to the computer it is sent to the triage que. In this que, we double check that the information is entered correctly, enter in or change a SIG code, enter days’ supply, and address other
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The first case where it is processed differently is if something is billed though Medicare part B. some example of things which are billed though part D include DME durable medical equipment, such as cane and nebulizer equipment, test strips, vaccines. When these are processed, we need to get a signature from the patient stating what we are filing to be valid. He stated with Medicare there are multiple different forms to be sent to Medicare. Another Issue with billing is when a patient has more than one insurance, but this can be handed in CVSs main filling program allowing for the billing of multiple insurances. Additionally, if a patient has a government insurance and a private insurance provider the private insurance is run first and then the government insurance is processed …show more content…
They ensure that this is done correctly is making sure that the information on the prescription matches what is dispensed and entered into the computer, and if issues arise at the cash register they also assist there also. Additionally, making sure that the correct diagnosis codes are entered into the computer as well. The most common error is days supplied being enter improperly. Having an error such as incorrect days supply can increase the amount of time it takes for a claim to get processed and therefore increasing the amount of time it can take to get that claim paid. When a claim is submitted incorrectly a pharmacist needs to call and corrected it. My preceptor said that technically anything entered incorrectly about the prescription can result in missed reimbursements through insurance. Although most issues that occur are handled through CVSs main processing hub such as claims, reimbursements, and charge backs. The CVS is the entity responsible for making sure claims are getting paid, and what the store gets back are totals of payments received but not a detailed breakdown of individual records of each
The IPPS or the inpatient prospective payment system refers to a system of payment which includes the diagnosis-related groups’ cases as acute care hospital inpatients. This system is based on resources which are utilized when treating Medicare recipients belonging to these groups. Each diagnosis-related group (DRG) comprise of a payment weight. The IPPS serves an integral role when it comes to deciding the overall hospital costs of all the devices used to treat the patient in within a specific inpatient stay.
I am truly amazed by the positive impact of bar-code medication administration (BCMA). Since we have a fully integrated electronic health record, it is a true closed loop-system, with medication order entry, pharmacy validation of medications, and clinical decision support. Implementing technology such as BCMA is an efficient way to improve positive identification of both the patient and medication prior to administration. It is estimated that the bar-code medication charting can reduce medication errors by 58% (Jones & Treiber, 2010). Even though we have good adoption of BCMA, nurses still make drug administration errors. In many of the cases, errors are caused by nurses, because they do not validate and verify. The integration of technology
According to Truitt et al. (2016) the study broke their examination up into the different phases of medication administration- prescribing or writing a medication order, transcription of the medication into the MAR, dispensing by the pharmacy, administration of the medication, and further monitoring after the administration. According to Truitt et al. (2016) about one-third of adverse drug events occur in the initial prescription phase and another one-third occurs during the administration phase. The one system, called the electronic medication administration record, is beneficial in cutting down the errors that occur in the transcription phase between the nurses and the pharmacy. According to Truitt et al. (2016) implementation of barcode medication administration record and the electronic medication administration record has reduced the amount of errors by 50% and serious errors by 25%. Truitt et al. (2016) also supports that it improves documentation, billing, and public
There are several errors that can occur in the billing and the coding process. When there’s a problem in the coding process it can cause rejected claims. Some of these problems consist of truncated coding, mismatch between the gender or age of the patient and the selected code when the code involves selection for either criterion, assumption coding (reporting items or services that were not documented, but that the coder assumes were performed), altering documentation after services are reported, coding without proper documentation, reporting services that are produces produced by unlicensed and or unqualified clinical personnel, coding a unilateral service twice instead of choosing the bilateral code, and not satisfying the conditions of coverage for a particular service. These errors can result in denials or payments being delay...
• Organize inventory and alert pharmacists to any shortages of medications or supplies • Accept payment for prescriptions and process insurance claims • Enter customer or patient information, including any prescriptions taken, into a computer system • Answer phone calls from customers • Arrange for customers to speak with pharmacists if customers have questions about medications or health matters Pharmacy technicians work under the supervision of pharmacists, who must review prescriptions before they are given to patients. In most states, technicians can compound or mix medications and call physicians for prescription refill authorizations. Technicians also may need to operate automated dispensing equipment when filling prescription orders. Pharmacy technicians working in hospitals and other medical facilities prepare a greater variety of medications, such as intravenous medications.
medications is more than the act of getting drugs to a patient. The delivery of medication is directly tied to the charge for the medication. Thus the responsibility for charging or crediting medication belongs to technicians. This aspect of their job is strictly governed by federal regulations. These laws hold the technician directly responsible for the accuracy of a patient’s account’s charge and credit transactions. Because every dose is related to a specific day and time, when technicians credit they must apply that change to the corresponding dose. Assignificant as accuracy is to the patient’s account, accuracy in the making of their medications is even more important.
Some method such as audits, chart reviews, computer monitoring, incident report, bar codes and direct patient observation can improve and decrease medication errors. Regular audits can help patient’s care and reeducate nurses in the work field to new practices. Also reporting of medication errors can help with data comparison and is a learning experience for everyone. Other avenues that has been implemented are computerized physician order entry systems or electronic prescribing (a process of electronic entry of a doctor’s instructions for the treatment of patients under his/her care which communicates these orders over a computer network to other staff or departments) responsible for fulfilling the order, and ward pharmacists can be more diligence on the prescription stage of the medication pathway. A random survey was done in hospital pharmacies on medication error documentation and actions taken against pharmacists involved. A total of 500 hospital were selected in the United States. Data collected on the number of medication error reported, what types of errors were documented and the hospital demographics. The response rate was a total of 28%. Practically, all of the hospitals had policies and procedures in place for reporting medication errors.
Giving out the wrong medication, or improper dosages can potentially be fatal to patients. Pharmacy technicians must be willing to take on this risk and do their work as carefully and accurately as possible.
... In summary, Medicare payment system is aimed at containing the rising cost of health care and enables providers to provide quality and coordinated care. Medicare uses the Medicare physician fee schedule to pay physicians and the outpatient prospective payment system to pay outpatient facilities. Bundle Payment is a way for paying for high volume, high cost hospital procedures. Global payment enables providers to reduce unnecessary care and bring down spending under control but creates incentives for providers to restrain the supply of services. The Obama administration recently made some changes to physicians and outpatient method of payment. The five levels clinic and outpatient codes have been replaced by a single code. Physicians will be reimbursed based on the chronic care management fee.
Responsibility and accountability become important when medical staff gives or doses patients with medication. The chance for making a medication error presents itself at all times. Those passing medications must follow established policies and procedures developed and laid forth by t...
What classifies as a Medication errors? An error can occur any time during the medication administration process. A medication error can be explained as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer” (National Coordinating Council for Medication Error Reporting and Prevention, 2014, para 1). Rather it is at prescribing, transcribing, dispensing or at the time of administration all these areas are equally substantial in producing possible errors that could potentially harm the patient (Flynn, Liang...
There are four components to the Medicare program, part A, B, C and D. Part A of Medicare covers in patient hospital services; patients have a financial responsibility to cover a deductible that is equivalent to 1 day of hospitalization, thereafter cost is covered at 100 percent for a maximum of 60 days. This also includes nursing facilities, home and hospice care. Part B covers outpatient surgery and physician office visits. This is an elective component of Medicare in that there is a premium associated with this plan that is paid for directly through social security payments. Part C is know as Medicare Advantage and is a supplemental policy that is purchased directly from employers; one may be denied for health reasons depending one when the plan is acquired. Part D is prescription drug coverage that is eligible to all individuals that qualify for Medicare. Beneficiaries of the Medicare choose which prescription plan they want and pay a corresponding monthly premium.
Nurses are expected to provide a competent level of care that is indicative of their education, experience, skill, and ability to act on agency policies or procedures. In a study of 1,116 hospitals Bond, Raehl, and Franke (2001) found, “Medication errors occurred in 5.07% of the patients admitted each year to these hospitals. Each hospital experienced a medication error every 22.7 hours (every 19.73 admissions). Medication errors that adversely affected patient care outcomes occurred in 0.25% of all patients admitted to these hospitals/year”(p. 4). This means at least one medication error occurs every 24 hours in those facilities studied, and these are preventable errors. The main responsibilities of nurses when administering medications are to prevent or catch error, and report such error. Even if the physician or prescribing health care professional has made a mistake in the order, it is the nurse’s job to question the
Medicare has four parts A, B, C, and D. Medicare Part A covers inpatient hospitalization, skilled nursing centers, hospice and some home health services. Medicare Part B covers some services not covered by Part A. Typically there is a premium charged for this coverage. Part B Covers medical supplies and outpatient visits. Medicare Part C, also known as Medicare Advantage plans are offered by private insurance companies which are in contract with Medicare. Medicare Part C provides you benefits from Part A, Part B and usually covers prescription drugs. This plan will cover most services. Last is Medicare Part D, Part D is a prescription drug program offered by private insurance companies. Part D allows drug coverage to the original Medicare plan. (Medicare.gov, 2016)
1. The two major differences between Medicare and Medicaid are who the plan is provided for and who is in charge of providing each plan. The majority of other differences stem from these two dissimilarities. Medicare is a health insurance plan for people over 65 years of age (also includes a few other smaller groups such as younger children with certain disabilities), while Medicaid is provided for citizens who cannot afford other healthcare insurance plans due to their low income. Because of this, Medicaid pays the providers less, so it is not uncommon that doctors will refuse to take patients who use Medicaid. Medicare, on the other hand, hardly ever negotiates prices, so doctors usually end up receiving what they charge. Medicare is completely