Billing & Stock
Terms:
Formulary- List of medications covered by insurance plans usually generics (less expensive)
Third party billing- Patient, pharmacy, insurance company. After patient pays his/her portion of drug cost, the pharmacy must submit an invoice for the remaining cost of payment to the insurance company
HIPAA Law (The Health Insurance Portability And Accountability Act Of 1996)- Signed into law by President Bill Clinton on August 21, 1996 to improve the health insurance system. This law is about protecting the privacy of the patient's healthcare information. Every healthcare professional are required to follow the HIPAA Law.
Reasons why a Rx may not be covered
Coverage expiration: If patient lost coverage, the pharmacy technician cannot call insurance to investigate (HIPPA Law). Must tell patient to call their insurance.
Limit Exceeded: Drug may not be covered in the insurance formulary, in this case a special authorization form must be submitted to the insurance company from the doctor explaining why the patient must have that specific drug. Another reason is that the prescription has a greater quanity amount of drug than is allowed by patient's insurance plan (some government insurance plans limit the number of prescriptions that can be filled per month or per year). If the prescription calls for a specific quanity of medication that exceeds the maximum amount to be filled per day, the prescription is rejected and the patient can contact the insurance company for special permission to obtain the drug (usually happens with diabectic & HIV drugs).
NDC not covered: Specific drug manufacture products is not included in formulary. The pharmacist can contact the doctor and request prescription to be changed to a drug that is covered under the patient's insurance plan. Another option is to submit a prior authorization form to insurance company indicating why the patient must take the non-formulary drug. The doctor usually fills out and submits the form for approval (process can take 2 weeks). If the patient pays untill medication is approved then the pharmacist fills out a reimbursement form for patient then the form is sent to the insurance company.
Rx too soon: Prescriptions usually are filled for 30-day supply, rarely 60-day & 90-day. The pharmacist can decide to fill a prescription depending on the type of medication. If the patient's insurance will not pay, then the patient is responsible for the cost. Sometimes doctors instruct patients to increase dosage forcing the refill process rejection. In this case a new prescription order must be submitted to insurance company or the technician must call the insurance company help desk to explain the circumstances of prescription changed. Some insurance companies require direct response from the patient's doctor before approval is given.
Stock (Inventory)
Facts:
:Each pharmacy technician orders formulary & non-formulary drugs
:Medications scanned at register (POS/point of sale system) is electronically computerized inventory list
:When in stock quanity drops to a certain level (PAR/periodic automatic replacement) it is reordered automatically
:Popular automated dispensing systems are Baker cell system, PYXIS, Omnicell......
:Order cards (card list) are written cards that have the right amount of stock to be ordered (info of drug) also known as periodic system. Determines drugs that are fast & slow movers
New stock- You will receive an invoice from the manufacture/warehouse. The invoice that decribes information of the drugs should match the ordered form. The invoice than should be signed and dated by the technician and sent for processing per pharmacy protocol. Once recieved order has been confirmed, the technician may put stock away <medications should not be allowed unless it has "good dating" (expiration date is long enough to use)>. Expiration is 3 months or less before expiration.
Returns- Reasons for drug returns may be drug recalls, damaged drugs, & expired drugs. Reasons for drug recalls results from label being described wrong, product was not packaged or produced properly, or drug batch was contaminated, etc. Recall notices may arrive by mail or fax. Immediately remove all recall products from stock according to specific lot number, & are to be sent back to the manufacture. Damaged drugs should be sent to manufacture also but before sending them the pharmacy must call first to get approval. Hazardous chemicals (cytotoxic agents) must be repackaged to avoid breakage during transportation.
EXTRA: FDA drug Approval process
- Sponsors (companies, research institutions, organizations,etc) who are developing a new drug must show the FDA results of preclinical testing they've done in laboratory animals & what they propose to do in human testing. At this stage the FDA decides whether if it is safe for the company to move forward with testing the drugs in humans
- Drug studies in human can begin only if an investigational new drug application (IND) is reviewed by the FDA & a local institutional review board (IRB). The board is a panel of scientists & non-scientists in hospitals & research institutions that oversees clinical research. When the IRB approves clinical trial in humans, they describe the type of people who may participate in trial, schedules of tests & procedures, medications & dosages to be studied, length of study, medication risks, etc.
- Phase 1: usually conducted in healthy volunteers, this phase determines what the drug most frequent side effects are & how often, how the drug is metabolized & excreted. (20 to 80 people involved)
- Phase 2: this phase begins forward if phase 1 does not reveal unacceptable toxicity. Determines drug effectiveness, also if drug works on people who have a disease or condition. (a few dozen to 300 people involved)
- Phase 3: this phase begins forward if phase 2 showed effectiveness of drug, which gathers more information on drug safety & effectiveness. This phase studies different populations & dosages & using drug combination with other drugs. (several hundred to 3,000 people involved)
- Sponsors ask FDA to approve their New Drug Application (NDA) that allows the drug to be marketed in the U.S. An NDA includes all animal & human data & analysis, how the drug behaves in the body, etc. FDA has 60 days to decide whether to file it so it can be reviewed. If FDA files the NDA, an FDA review team is assigned to evaluate the sponsor's research of the drug safety & effectiveness, also reviews drug professional labeling (info on how to use the drug). It can take years for a drug to be in the market
- FDA inspects the facilities where the drug is going to be manufactured as part of the approval process
- If the drug meets FDA standards then the application is approved and ready to be in the market
