CHAPTER 13: Pharmacy Billing and Inventory Management

Medication temperatures for room temperature:

23 degrees Celcius

Which group is not covered by Medicare? A) Healthy infants B) Disabled patients C) Seniors D) Dialysis patients

A

Which of the following is not a type of health insurance plan in use today? A) POS B) HMO C) PPO D) Medicare

A

Which of the following is not an example of an inventory system that can keep a running inventory of medications, as well as order them? A) SOC system B) POS system C) Order card system D) Handheld computer inventory system

A

Which regulatory body can issue a drug recall? A) FDA B) TJC C) DEA D) BOP

A

TRUE

A PPO plan usually has a higher copayment than an HMO.

FALSE

A formulary is a book that contains compounding recipes.

TRICARE

A health benefit program for active-duty and retired personnel in all seven uniformed services; also covers dependents of military personnel who were killed while on active duty.

OPEN FORMULARY

A list that is essentially unrestricted in the types of drug choices offered or that can be prescribed and reimbursed under the health provider plan or pharmacy benefit plan.

TRUE

A pharmacy technician often is put in charge of billing.

CHAMPVA

A program for veterans with permanent service-related disabilities and their dependent, and spouses and children of veterans who died from service-connected disability.

JUST-IN-TIME ORDERING

A system that orders a product just before it is used.

CLOSED FORMULARY

A tightly restricted list of medications that are preapproved by the health plan provider or pharmacy benefits manager for reimbursement.

COINSURANCE

A type of insurance in which the policyholder pays a share of the payment made against a claim.

What are the three main responsiblities of automated return companies?

All records, recalled items, disposal of hazardous waste.

HMO

Allows coverage for in-network only physicians and services.

PPO

Allows patients to choose a physician with reduced costs for medical services.

A one for DAW code means _________________. A) No refills B) Dispense order as written C) Generic substitution authorized D) Patient would like brand name only

B

An inventory system that automatically orders stock as it is used is called: A) Pyxis B) POS C) Omnicell D) Baker cell

B

Reasons for obtaining a prior authorization may include _______________________. A) Patient is demanding the drug B) Drug of choice not formulary C) Pysician is requesting D) All of the above

B

The types of drugs typically included in a formulary are: A) New drugs B) Generic drugs and common branded drugs for which no generic is available in the drug class C) Uncommon drugs D) Extremely expensive drugs

B

When a workers' compensation claim arrives at the pharmacy, the technician must: A) Obtain permission from a government agency at a later time. B) Obtain information from the patient's human resources department C) Collect payment from the patient, who then will be reimbursed is made by the insurance company before releasing the medication. D) Wait until payment is made by the insurance company before releasing the medication.

B

Which of the following is not a difference between HMOs and PPOs? A) A PPO plan has no requirements for a PCP B) PPO plans have a copayment C) PPO plans have a deductible D) All of the above are differences

B

Which of the following is not a reason for the insurance company to reject a claim? A) Coverage has expired B) Use of generic drug C) Refill to soon D) NDC not covered

B

Which of the following is responsible for developing the formulary used by an institution? A) State board of pharmacy B) Pharmacy and therapeutics committee C) Food and Drug Administration D) All of the above

B

A zero for a DAW code means ________________. A) No refills B) Dispense order as written C) Generic substitution authorized D) All of the above

C

In third-party billing, the third party is the: A) Pharmacy B) Patient C) Insurance company D) All of the above

C

Insurance claims that are transmitted electronically to the insurance provider are called: A) E-mail claims B) NDC claims C) Adjudicated claims D) Co-pay claims

C

Medicare is a government-managed insurance program that covers all of the following except: A) Senior citizens B) Patients using dialysis C) Children D) People who are disabled

C

The amount a patient must pay before the copay starts is called the : A) Share of cost B) Penalty period C) Deductible D) Grace period

C

Which health plan covers in-network provider visits only? A) A medical group that is covered under Medicare B) Preferred provider organization (PPO) C) Health maintenance organization (HMO) D) Point of service plan (POS)

C

Which of the following is not a government-run insurance program? A) Medicare B) Medicaid C) Long-term disability D) Worker's compensation

C

Which of the following is not a reason to return medications to the warehouse or manufacturer? A) Drug recalled B) Drug damaged during delivery C) Drug incorrectly reconstituted D) Drug expired

C

Describe: Class II recalls

Can cause temporary health problems & low risk of serious problems

List the three classes of drug recalls.

Class I, Class II, and Class III

WHOLESALERS

Companies that stock a variety of drug manufacturers' medications and normally have a "just-in-time" turnaround for ordered drugs.

List four common reasons a prescription may not be covered.

Coverage has expired, coverage limits have been exceeded, patients trying to refill to early, the cardholders information does not match the processor's information.

What does Medicare Part A cover?

Covers institutional cost if the participant meets the criteria established by federal & state regulations.

What does Medicare Part B cover?

Covers physician & other outpatient services, including diabetes testing, etc...

TRUE

Cytotoxic drugs require special packaging when they are returned to the manufacturer.

Drug utilization evaluation (DUE) is an important process used to screen the medication order for: A) Duplicate therapy B) Possible errors C) Drug-drug interactions D) All of the above

D

Manufacturers are required by law to recall any product that has been found to have which of the following guideline violations? A) Labeling is wrong B) Product was not packaged or produced properly C) Drug batch was contaminated D) All of the above

D

Medicaid covers all of the following except: A) People who are disabled B) People with a low income C) Women who are pregnant D) Single working people with above-average income

D

Point-of-sale billing allows the insurance company to _________________. A) Price a claim B) Verify eligibility C) Identify covered drugs D) All of the above

D

Sometimes insurance companies refill medications early because: A) The patient lost the medication B) The patient is going on a vacation C) The physician told the patient to increase the dosage D) All of the above

D

The insurance company decides the amount of coverage per medication based on: A) AWP B) Copay C) DAW D) A and B

D

Various types of agents ordered for a pharmacy may include: A) Formulary drugs B) Hazardous substances C) Cytotoxic drugs D) All of the above

D

Which of the following is not aspecial feature of an HMO? A) Primary care physician B) Independent physicians' association C) Copayment D) Worker's compensation

D

Which program makes prescription drugs avail-able through private insurance plans? A) Medicare Part A B) Medicare Part B C) Medicare Part C D) Medicare Part D

D

Who is responsible for maintaining the inventory stock in the pharmacy? A) Pharmacist B) Technician C) Inventory technician D) All of the above

D

DIRECT MANUFACTURER ORDERING

Directly contracting with and ordering from the manufacturer to obtain better pricing; may join a GPO

Describe: Class I recalls

Drugs that may pose a serious threat to user's health or death

TRUE

Each insurance plan has specific guidelines that must be followed for reimbursement.

ADJUDICATION

Electronic insurance billing for medication payment.

FALSE

Generic drugs are less expensive because they are less effective than brand name drugs.

MEDICARE

Government-managed insurance program composed of several coverage plans for health care services and supplies for individuals 65 years or older, younger than 65 with long-term disabilities, or those suffering from end-stage renal disease.

MEDICAID

Government-managed insurance program that provides health care services to low-income children, the elderly, blind, and those with disabilities.

WORKERS' compensation

Government-required and government-enforced medical coverage for workers injured on the job, paid for by the employer.

One of the most common problems resulting in a claim rejection is a non-ID match. What patient information should be double-checked in these cases?

Health plan card number, identification number, and insurance number. Patient's name, dob, & relationship to the insured person.

FALSE

If the cardholder's information does not match the processor's information, the patient does not have coverage.

FALSE

In a PPO, the patient must select a physician from the insurance plan's list.

SAFETY DATA SHEETS (SDS)

Information sheets supplied to the pharmacy from the manufacturer of chemical products; lists hazards of the product and procedures to follow if exposed to that product.

PRIOR AUTHORIZATION

Insurance-required approval for a restricted, non-formulary, or noncovered medication before a prescription medication can be filled.

What does Medicare Part C cover?

Known as Medicare Advantage - Optional plan to part A&B, private plan etc.

PRIME VENDORS

Large distributors of medications and retail products that contract with the pharmacy to deliver the bulk of their medications in exchange for lower prices.

TRUE

Many formulary drugs are generic versions of proprietary products.

P&T COMMITTEE

Medical staff composed of physicians, pharmacists, pharmacy technicians, nursers, and dieticians who provide necessary information and advice to the institution or insurer on whether a drug should be added to a formulary.

What are the four Medicare levels available?

Medicare Part A Medicare Part B Medicare Part C Medicare Part D

FALSE

Medications taken out of the pharmacy by a patient can be returned to stock.

NATIONAL PROVIDER IDENTIFIER (NPI)

Number assigned to any health care provider that is used for the purpose of standardizing health data transmissions.

TRUE

One of the best ways to learn drug names and to become familiar with their locations in your pharmacy is to put away new stock.

When a pharmacy is billing for medication, what is the minimum information the insurance company requires?

Patients name, date of birth, identification number, date medication was filled, pharmacy name & address, medication prescribed, dosage.

PAR

Periodic automatic replenishment of stock levels to a certain number of allowed units.

DEDUCTABLE

The amount paid by a policyholder out-of-pocket before the insurance company will pay a claim.

FALSE

The cost of prescriptions is the same from pharmacy to pharmacy.

MEDICARE MODERNIZATION ACT (MMA)

The enactment of prescription drug coverage provided for persons covered under Medicare.

COPAYMENT

The portion of the prescription bill that the patient is responsible for paying.

TREATMENT AUTHORIZATION REQUEST (TAR)

The process used for Medicare and Medicaid preapproval for assistive technology devices with a cost of more than $100.

Why do many pharmacies have a policy of pulling any medication off the shelves that will expire in 3 months or sooner?

This ensures that no drugs on the shelves are close to their expiration date.

Describe: Class III recalls

Violate FDA regulations concerning container defects or strange taste or color.

TRUE

When the shipment arrives, all included medications and supplies must be verified against the inventory list.

A _________________ ________________ can identify the drug, strength, dosage form, quantity, cost, package size, and any other information necessary about a drug.

bar code

Medication temperatures for freezer:

between -20 degrees and -10 degrees Celsius

Medication temperatures for refrigerator:

between 2 degrees and 8 degrees Celsius

___________________ is a method of payment in which the doctor receives a fixed amount for each member patient regardless of how many times the patient visits the physician.

capitation

Falsely billing charges for medication that was not dispensed is a _______________.

crime

For medications to become part of a formulary, they must meet certain requirements such as ________________________ and _________________

effectiveness cost

_____________________ ______________________ focuses on ordering stock, proper storage of medication and supplies, repackaging, disposal of used and unused pharmaceutical products, and distribution systems.

inventory management

Everyone working in the pharmacy is responsible for maintaining the ___________________ _________________.

inventory stock

If the patient must self-bill the insurance company for reimbursement, then the patient will need the ____________________ to submit to the insurance company.

receipt

Regardless of the patient's type of insurance, you should always treat people with ___________________.

respect

A percentage of each ______________ ______________ is applied toward Medicaid.

state budget

The term ______________-______________ _____________ refers to the portion of payment reimbursed by insurance companies.

third-party billing

FALSE

Recall notices arrive by voice mail.

INVENTORY

Refers to the amount of product a pharmacy has for sale.

What does Medicare Part D cover?

Specifically covers prescription drugs. Provided by individual private insurance etc...

TRUE

Storing medications in the proper location is the responsibility of everyone working in the pharmacy.

MEDIGAP plans

Supplemental insurance policies provided through private insurance companies to help cover costs not reimbursed by the Medicare plan, such as co-insurance, co-pays, and deductables.

POS

System that allows inventory to be tracked as it is used.

The pharmacy name and address is used by insurance to assure payment goes to the pharmacy. TRUE or FALSE

TRUE