Point of Sale (POS) Pharmacy Billing

1. Point of Sale (POS) Pharmacy Billing

2. Housekeeping • 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

3. Objectives • 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.

4. Training Plan • 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

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

6. Key Components to Using RPMS POS • Coordinated effort: Business Office, IT, Pharmacy • Best – “hire or assign pharmacy biller” • Having the necessary menus/keys • Network participating agreements • Staying current with software patches • 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

7. Pharmacy Benefit Management (PBM’s) • 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

8. PBM Web Site • See handout with links

9. 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 V5.1 • Addendum

10. 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 • MedImpact – review • Argus – signing process • PCN – signing process • Pharmacare - review

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

12. Outpatient Pharmacy Package – Drug File, continued…. • Mailman message – lists unmatched drugs • EAWP – Outpatient 6.0 • AWP Manual Update • Outpatient Pharmacy v 6.0 patch 5 • Outpatient Pharmacy v7.0 – new version (10/2004) – 46 sites using

13. 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 500MG INJ - DISP UNITS DON'T MATCH - Medi = 90 / Local = 1 ACYCLOVIR 200MG/5ML SUSP,ORAL - DISP UNITS DON'T MATCH - Medi = 473 / Local =480

14. Drug AWP Edit - EAWP Select DRUG GENERIC NAME: GLYBURIDE 5MG 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

15. Formats • NCPDP field names/numbers – POS / RPT / OTHR • Or see handout • WebMD: switch company –– GSA contract - $ 0.025/transaction • Information needed when adding a new insurer/format: • Processor • BIN number • Plan name/number • Processor Control Number (PCN) or carrier ID • Help desk phone number • Requesting a new format

16. Patient Registration • Insurer Name • Employer Group name/number • Table Maintenance • Person code • Ideas for collecting patient registration information

17. POS Set-up • POS / MGR / Set-up • BAS • Pharm • INS • BILL • PROV • SUMI

18. POS Menu’s • Reports • CLA / PAY, REJ, PAP, URM, DAY, INS • Survey

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

20. Using POS • User Menu • Live Claims • Payable claim to RPMS A/R package

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

22. Rejection Handout

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

24. Resources • 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

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

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

27. Backbilling • Electronic limitations (# days to backbill) • Prescription number • POS / U / N

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

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

30. Universal Claim Form (UCF) • Part of 3PB package • Need to order forms: • Moore North America, Inc. • Moore National Customer Service Center: (800) 635-9500 • For version 5.1, HIPAA compliant item # DAH2PT: • 1500 forms per carton – 9 ½’’ x 11”, continuous pin feed; $56.21 per carton ($0.04 per form) + shipping

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

32. HIPAA – Pharmacy • 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

33. Wrap-Up • Action plan