Point of Sale POS Pharmacy Billing Housekeeping

Point of Sale (POS) Pharmacy Billing

Housekeeping l l l Verify you can log into you facility Verify that you have the POS menus (if you are using POS) Verify you can print to the printer in the room

Objectives l l Describe the general principals of pharmacy billing. Describe processes that need to be in place to be successful at pharmacy billing List the reports are available in RPMS POS? Describe how to correct different types of rejections using the POS software.

Training Plan l l l Reference – FTP site: ftp: //ftp. ihs. gov/rpms/POS/ Understand RPMS software – POS set-up Learning business end of pharmacy billing to maximize collections Network agreements (contracts), review insurers set-up Audits, HIPAA, programming plans/projects

Point of Sale Pharmacy Billing Outpatient Pharmacy package Patient Registration package Patient Care Component (PCC) - visit files RPMS system Third Party Billing & Accounts receivable packages Point of Sale package Switch Processor Response

Key Components to Using RPMS POS l Coordinated effort: Business Office, IT, Pharmacy – l l l Having the necessary menus/keys Network participating agreements Staying current with software patches – – l l Best – “hire or assign pharmacy biller” Outpatient Pharmacy 6. 0, patch 5 or Outpatient Pharmacy 7. 0, patch 3 POS version 1, patch 13 AWP (APSA) and Patient Education (APSE) updates http: //www. ihs. gov/Cio/RPMS/index. cfm? module=home&option=index Drug file clean-up Patient registration

Pharmacy Benefit Management (PBM’s) l l l An organization that manages pharmaceutical benefits for employers, other providers or managed care organizations Involved in: Benefit plan design, Claims processing, Formulary management, Manufacturer rebates, DUR review Examples of PBM’s: Medco Health, Caremark, Express Scripts, First Health (Coventry), Rx America

PBM Web Site l See handout with links

Network Agreements § § § Patient Insurance Card Network enrollment application Vendor Information § Software vendor: Indian Health Service § § § 5300 Homestead Rd, Albuquerque, NM 87110 Software: RPMS POS, NCPDP V 5. 1 Addendum

Status of Agreements - IHS § National § § Express Scripts, First Health (Mail Handlers), Medicare Drug Card (PCA, Criterion) Medco Health Medicare Part D – January 1, 2006 (several) In the works: § § § § Tricare/Express Scripts – signing process Caremark - review Aetna – review Med. Impact – review Argus – signing process PCN – signing process Pharmacare - review

Outpatient Pharmacy Package l l SFUN / SITP / IHSP - location of POS “switch” Drug file – AWP monthly updates l l http: //www. ihs. gov/CIO/Info. Tech_index. asp APSA APSE – Patient Education - quarterly Status of patches – Outpatient Pharmacy Supervisor Menu - Maintenance

Outpatient Pharmacy Package – Drug File, continued…. l Mailman message – lists unmatched drugs – – EAWP – Outpatient 6. 0 AWP Manual Update Outpatient Pharmacy v 6. 0 patch 5 Outpatient Pharmacy v 7. 0 – new version (10/2004) – 46 sites using

AWP Manual Update Subj: Outpatient Pharmacy AWP Automatic Update [#12914] 16 Nov 04 12: 21 200 Lines From: OUTPATIENT PHARMACY DEVELOPER in 'IN' basket. Page 1 **NEW** ---------------------------------------An Average Wholesale Pricing update was performed on your system on 3041116. The total number of records updated = 924 Listed below are the active drugs that were not updated and the error codes. Please review and correct all errors before attempting to run the manual AWP update option. Note: any 'missing 660 node' errors means that information like Order Unit, Price Per Order Unit, Dispense Units Per Order unit, Price Per Dispense Unit, etc) is missing! ACETAZOLAMIDE 500 MG INJ - DISP UNITS DON'T MATCH - Medi = 90 / Local = 1 ACYCLOVIR 200 MG/5 ML SUSP, ORAL - DISP UNITS DON'T MATCH - Medi = 473 / Local =480

Drug AWP Edit - EAWP Select DRUG GENERIC NAME: GLYBURIDE 5 MG TAB ORDER UNIT: BT// DISPENSE UNIT: TAB// DISPENSE UNITS PER ORDER UNIT: 1000// AWP PER ORDER UNIT: 825. 69// AWP PER DISP UNIT is. 82569 AWP EFFECTIVE DATE: JUN 5, 2001// NDC: 00009 -0171 -07// DEA, SPECIAL HDLG: 6// LAST PRICE UPDATE: INACTIVE DATE: PRICE PER ORDER UNIT: 17. 31// PRICE PER DISPENSE UNIT is 0. 017

Formats l NCPDP field names/numbers – POS / RPT / OTHR – l l Web. MD: switch company –– GSA contract - $ 0. 025/transaction Information needed when adding a new insurer/format: – – – l Or see handout Processor BIN number Plan name/number Processor Control Number (PCN) or carrier ID Help desk phone number Requesting a new format

Patient Registration l l Insurer Name Employer Group name/number – l l Table Maintenance Person code Ideas for collecting patient registration information

POS Set-up l l l l POS / MGR / Set-up BAS Pharm INS BILL PROV SUMI

POS Menu’s l Reports – – CLA / PAY, REJ, PAP, URM, DAY, INS Survey

Setting up an Insurer – POS / MGR / SET / INS l l l INS – RPMS insurer, POS Format (use Excel spreadsheet) ADV – assign priority points RPMS – set to P

Using POS l l User Menu Live Claims – Payable claim to RPMS A/R package

POS Rejections l How often to run reports? – l l l Ideally – rejection report daily Need process to address them. Coordinated between Business office and Pharmacy See Reject codes

Rejection Handout

POS Rejections l l l Cardholder ID, Group number, eligibility Refill too soon, NDC, Day supply, drug not covered DUR, Prior Auth, Prescription Clarification code

Resources l l Web Links – handout Payer Help Desk – see POS rejection report for phone number. – Before calling, have claim pulled up: POS / U / EV / 3 -Patient name / REC

POS Rejections l DUR override: Show Rx Bill or POS / U / N – – – l 439 REASON FOR SERVICE CODE 440 PROFESSIONAL SERVICE CODE 441 RESULT OF SERVICE CODE See handout for DUR codes

Prior authorization l Can be input in either of these packages: – – Show Rx Bill (Pharmacy package) or POS / U / N (POS package) Example l Refill too soon due to dosage change: 98798798798

Backbilling l l l Electronic limitations (# days to backbill) Prescription number POS / U / N

Troubleshooting l l RPMS support Network issues, changing internet providers, maintenance by payers. Taskmanager Cache conversion

Network Agreements l l Verify processor, patient name, employer Addendum National contracts, Regional, Facility contracts NCPDP Provider Number update

Universal Claim Form (UCF) – – Part of 3 PB package Need to order forms: l l Moore North America, Inc. Moore National Customer Service Center: (800) 635 -9500 For version 5. 1, HIPAA compliant item # DAH 2 PT: 1500 forms per carton – 9 ½’’ x 11”, continuous pin feed; $56. 21 per carton ($0. 04 per form) + shipping

Audits l l Three to five years of records, payable claims – read contract to verify. Copy of Rx – l l Hard copy readily retrievable Copy of Prior Auth (PA) Signature log

HIPAA – Pharmacy l Policy and Procedures addressing the following: – – – Privacy consultation area Staff Training on HIPAA Medication pick-up by proxy Disposal or destruction of patient drug history information Leaving information on patient’s home or work answering machines Confidentiality Forms

Wrap-Up l Action plan