Microsoft powerpoint - brandon_young_sas_pharmacy_presentation.pptx

B R A N D O N Y O U N G , P H A R M D C A N D I D A T E , U N I V E R S I T Y O F M I N N E S O T A C O N T A C T W I T H A N Y Q U E S T I O N S The pharmacy is responsible for initiating the prescription claim process by entering patient information as data.
Often after claims goes through adjudication a rejection is generated that the pharmacy must address.
Some reasons for rejections are ensure proper medication use, reduce waste, and minimize cost.
Despite these intentions, some rejections do not serve their purpose and cause unnecessary stress for patients and may By understanding some of these quirks we hope to minimize Enter patient, prescription, and billing information •Prescriber ID•Date written•Date filled A prescription for Xalatan 0.005% is processed for a 50 days supply, but rejected due to Billed as a 30 days supply, but dispensed 50 days worth.
The third party is blinded to the last 20 days of therapy.
A prescription for Celexa 20 mg twice daily rejects due to Indication versus clinical practice.
The patient is late in receiving their medication.
The patient suffers side effects from once daily dosing.
The patients conditions is inadequately treated.
Prescription for Adderall XR 20 mg is rejected for ICD-9 code is not provided or does not match medication.
The patient must pay full price for the prescription.
The prescriber is consulted, delaying initiation of therapy.
The pharmacy falsely enters any ICD-9 code that works.
Prescription for Advair 250/50 mcg is billed using a manufacturer The coupon seems legitimate, but there is some limitation to it’s use The pharmacy spends a lot of time trouble shooting, delaying initiation of therapy.
The patient withdraws the prescription out of frustration or inability to pay.
The patient pays full price.
A prescription claim for lisinopril 10 mg rejects due to A mail order pharmacy was late in filling the prescription, and the medication is “in the mail.” The patient pays full price at the community pharmacy.
The patient goes without medication waiting for the There are many cases where prescriptions are rejected due to various PA REQUIRED PT NOT MET STEP THERAPY NOT ELIG FOR NDC Though valid in many cases, there are lots of examples when the patient has met the required criteria, but the paperwork hasn’t been filed, has been entered incorrectly, or there is some other miscommunication.
The patient becomes angry at the pharmacy or third party.
The patient goes without their medication.
The prescriber changes the medication, changing quality of therapy.
The prescriber obtains PA, delaying initiation of therapy.
A prescription is successfully billed for Benicar 10 mg, but 14 days later the claim is reversed.
Noncompliance makes it hard to anticipate when a patient will require a refill of medication.
The pharmacy has extra workload in reversing and re-running the claim.
The third party sees multiple claims and reversals.
Either of these can result in miscommunication or errors.
A prescription for hydrochlorothiazide 25 mg is processed at a cost of $4.00 but returns with a $4.08 co-pay.
$4.00 generics undercut the cost of the medication.
The patient refuses to pay the $0.08 and requests the claim is not billed through their third party.
The pharmacy forgoes third party billing in anticipation.
The pharmacy is responsible for initiating the prescription claim process by entering patient information as data.
Often after claims goes through adjudication a rejection is generated that the pharmacy must address.
Some reasons for rejections are ensure proper medication use, reduce waste, and minimize cost.
Despite these intentions, some rejections do not serve their purpose and cause unnecessary stress for patients and may By understanding some of these quirks we hope to minimize

Source: http://www.minneanalytics.com/files/Brandon_Young.pdf