Dr.M

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Its Z

Its Z

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How do you know if your adjudication was paid fully per contract on all the claims?
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Z:
When you are in independent, you look at each rx as it is adjudicated. You submit the claim to the PBM and they send back a response with the amount paid as the ingredient cost, the dispensing fee, any ancillary fees, the patient copay and the amount you will be paid for those claims. When the remittance comes, you then reconcile the amount paid on the remittance with the amount stored in your system from the on-line adjudication. At least that;s how we used to do it in the dark ages when I worked at an independent.

ALL retail claims are adjudicated at the POS. You are given an approval or a denial and if it is approved, you get the information above. A paid claim however is not the goal. The goal is a paid claim that can survive an audit. For example if a patient is on Imitrex 100mg tablets with an RX for 30 tablets as directed, you might get a paid claim. However, upon audit that claim would be reduced to 8 or 9 tablets as the maximum dose of Imitrex in the PI is 200mg and the maximum number of attacks you should treat per month is 4. To get a paid claim for 30 tablets you would have to have documentation that the patient is treating X headaches per month to match what you are dispensing.
 
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But how do you knoe th full amount of reimbursement has been adjudicated and actually hit the bank?
 
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Its Z said:
But how do you knoe th full amount of reimbursement has been adjudicated and actually hit the bank?
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You get a check, either from the third party or via your PSAO.

As far as whether the amount is "per contract," some PBMs won't tell you how they calculate their reimbursement rates, so every time you adjudicate, it's a surprise. And usually not a good one.
 
We are doing EMR and CPOE conversion right now and I have a proposal to start a retail pharmacy in place. 340 discharge prescriptions, employee scripts etc. Pretty exciting stuff.
 
All4MyDaughter said:
You get a check, either from the third party or via your PSAO.

As far as whether the amount is "per contract," some PBMs won't tell you how they calculate their reimbursement rates, so every time you adjudicate, it's a surprise. And usually not a good one.
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:smuggrin:

I know.... I bought into a prepost adjudication audit company..... I know nothing about it but my buddy said to trust him. And I do. So I did.
 
Z: You get a remittance listing each rx and the amount paid. You reconcile that against your Computer system. If you are looking at a computer system Contact HBS. They are far and away the best in the business. Software is powerful and easy to use.
 
Old Timer said:
Z: You get a remittance listing each rx and the amount paid. You reconcile that against your Computer system. If you are looking at a computer system Contact HBS. They are far and away the best in the business. Software is powerful and easy to use.
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So who does the reconcilliation?
 
Its Z said:
We are doing EMR and CPOE conversion right now and I have a proposal to start a retail pharmacy in place. 340 discharge prescriptions, employee scripts etc. Pretty exciting stuff.
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Wow :thumbup: 'grats if all goes well! :xf:
 
Your staff. It's cheaper than paying someone else to do it. Your pharmacists should be checking the reimbursement as you go to make sure it's proper and then your staff will match that with the remittance. It doesn't take that long.
 
Old Timer said:
Your staff. It's cheaper than paying someone else to do it. Your pharmacists should be checking the reimbursement as you go to make sure it's proper and then your staff will match that with the remittance. It doesn't take that long.
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Software my man....
 
Its Z said:
Software my man....
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It's built into the HBS system. It tracks unpaid claims. I know it's there because when they tried to sell it to my stepfather in the early 80's he made them write the code for it or he wouldn't buy it. Any pharmacy system that does not track receivables is not worth purchasing.

Fly into Philly, I'll pick you up at the airport. We'll stop for a real cheese steak and then you can spend an afternoon at HBS and look it over. I get no commission on this, just in case you think I'm a shill. If I were ever to open a pharmacy, I would install HBS in a heartbeat....
 
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Old Timer said:
It's built into the HBS system. It tracks unpaid claims. I know it's there because when they tried to sell it to my stepfather in the early 80's he made them write the code for it or he wouldn't buy it. Any pharmacy system that does not track receivables is not worth purchasing.

Fly into Philly, I'll pick you up at the airport. We'll stop for a real cheese steak and then you can spend an afternoon at HBS and look it over. I get no commission on this, just in case you think I'm a shill. If I were ever to open a pharmacy, I would install HBS in a heartbeat....
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I probably will. I've done the Genos and pats.....but this local joint by the airport had a killer cheese steak!
 
Its Z said:
I probably will. I've done the Genos and pats.....but this local joint by the airport had a killer cheese steak!
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Geno's and Pats are the one time thing to say you ate a cheese steak standing over a trash can at 9th & Passyunk. Cheese Steaks in Philly are like Beer in Germany. There is a joint on every corner and everybody thinks the one they go to is the best.... The secret is fresh meat and good rolls.....
 
Its Z said:
I probably will. I've done the Genos and pats.....but this local joint by the airport had a killer cheese steak!
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Geno's and Pat's are meh.

Go into the Reading Terminal Market in the middle of town and get a Dinic's roast pork sammich with broccoli rabe and sharp provolone. It's better than a cheesesteak.
 
Old Timer said:
Z:
When you are in independent, you look at each rx as it is adjudicated. You submit the claim to the PBM and they send back a response with the amount paid as the ingredient cost, the dispensing fee, any ancillary fees, the patient copay and the amount you will be paid for those claims. When the remittance comes, you then reconcile the amount paid on the remittance with the amount stored in your system from the on-line adjudication. At least that;s how we used to do it in the dark ages when I worked at an independent.

ALL retail claims are adjudicated at the POS. You are given an approval or a denial and if it is approved, you get the information above. A paid claim however is not the goal. The goal is a paid claim that can survive an audit. For example if a patient is on Imitrex 100mg tablets with an RX for 30 tablets as directed, you might get a paid claim. However, upon audit that claim would be reduced to 8 or 9 tablets as the maximum dose of Imitrex in the PI is 200mg and the maximum number of attacks you should treat per month is 4. To get a paid claim for 30 tablets you would have to have documentation that the patient is treating X headaches per month to match what you are dispensing.
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And this can be done simply by writing on the rx harcopy "MD treating 30 headaches in 30 days"??

I know its bad medicine, but that's fine right?
 
You better have documented who you spoke to, the date and the time. I tend not commit insurance fraud. Then when they renew the 30 tablets every six months, you are sunk. The best thing to do is be honest.
 
WVUPharm2007 said:
Geno's and Pat's are meh.

Go into the Reading Terminal Market in the middle of town and get a Dinic's roast pork sammich with broccoli rabe and sharp provolone. It's better than a cheesesteak.
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Meh, did DiNic's once. I actually wasn't that big of a fan. I think I just didn't like the broccoli rabe, maybe gonna have it again with peppers instead.

As far as cheesesteaks go, I had Geno's once. I liked it. Never went to Pat's. When people are visiting me and want a cheesesteak, I normally take them to Steaks on South. Just as good (if not better than) Jim's, no lines, and they often give free fries. They also have ample indoor seating.
 
Can't believe you fools jacked my thread.
 
bacillus1 said:
Meh, did DiNic's once. I actually wasn't that big of a fan. I think I just didn't like the broccoli rabe, maybe gonna have it again with peppers instead.

As far as cheesesteaks go, I had Geno's once. I liked it. Never went to Pat's. When people are visiting me and want a cheesesteak, I normally take them to Steaks on South. Just as good (if not better than) Jim's, no lines, and they often give free fries. They also have ample indoor seating.
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Everyone is better than Geno's, Pat's, and Jim's.

I'ma go with Chink's in the city. Altomonte's Italian Deli in the Burbs.
 
Its Z said:
How do you know if your adjudication was paid fully per contract on all the claims?
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Old timer has it right, but with having 2 pharmacies, we dont do our own recon. We would be there 24/7. We pay a company to do it. We get soooo many recon sheets (Medco, Prescription solutions, medicaid etc etc). You pretty much are blind to recon unless you spend every moment doing it.
 
Doctor M said:
Old timer has it right, but with having 2 pharmacies, we dont do our own recon. We would be there 24/7. We pay a company to do it. We get soooo many recon sheets (Medco, Prescription solutions, medicaid etc etc). You pretty much are blind to recon unless you spend every moment doing it.
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You finally show up. OK.... do you use relay health to adjudicate?
 
Its Z said:
You finally show up. OK.... do you use relay health to adjudicate?
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Haha, man, ive been at the beach. We use eRX (Emdeon) switch. I think we have the option to use eRX of relay health via our software company.
 
Doctor M said:
Haha, man, ive been at the beach. We use eRX (Emdeon) switch. I think we have the option to use eRX of relay health via our software company.
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Cool. Im just trying to learn this stuff...
 
Dr. M which company do you go through to do your reconciliation? How much does it cost? I need to look into it myself.

Btw has anyone else noticed fishy adjucations where is says something like "-3.00" lately? Like I will get a paid claim where 10.00 is adjucated, -3.00 is what the insurance pays, and the patient pays 13.00. What is up with that? Am I going to get a bill for 3.00 just for the pleasure of running the claim?
 
southpharmindy said:
Dr. M which company do you go through to do your reconciliation? How much does it cost? I need to look into it myself.

Btw has anyone else noticed fishy adjucations where is says something like "-3.00" lately? Like I will get a paid claim where 10.00 is adjucated, -3.00 is what the insurance pays, and the patient pays 13.00. What is up with that? Am I going to get a bill for 3.00 just for the pleasure of running the claim?
Click to expand...

Ive seen this with certain claims also. Usually with a discount card. I reverse the claim and just charge pt what the it said to charge. Strange.
 
Old Timer said:
The goal is a paid claim that can survive an audit. For example if a patient is on Imitrex 100mg tablets with an RX for 30 tablets as directed, you might get a paid claim. However, upon audit that claim would be reduced to 8 or 9 tablets as the maximum dose of Imitrex in the PI is 200mg and the maximum number of attacks you should treat per month is 4. To get a paid claim for 30 tablets you would have to have documentation that the patient is treating X headaches per month to match what you are dispensing.
Click to expand...

As someone who was once involved in the health plan / PBM world, this is disturbing...

The "old way" was to verify the need for the script at the POS through a PA/MN process, and fail to provide coverage (reject) all scripts that didn't meet the required criteria. This process would piss off the patient and the physician, but left the pharmacist off the hook.

The "new way" is to let the script through, go conduct an audit 6 months to 2 years later, and take back payment for any script deemed invalid. This lets the physician and the patient off the hook (and frankly, both are happy- the script got filled and consumed), and increasingly places the [financial and paperwork] burden upon the dispensing pharmacist. All this for a dwindling dispensing fee per filled script.

Funny how they never audit those generic atenolol scripts where the daily dose comes in a smidge higher than the max dose listed in the PI.

Doc M and Old Timer- you have my sympathies!
 
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