Insurance is hard to come by if you are unemployed, self-employed, or working part-time or for a small business that do not offer insurance. In some cases you may qualify for Medicare if you are sixty-five and older or disability. Otherwise your best bet is seeing if you’re eligible for Medicaid. President Obama signed the Affordable Care Act (ACA) on March 23, 2010, into law putting in place comprehensive reforms that improve access to affordable health coverage for everyone and protect consumers from abusive insurance company practices.
(Reform) This new health care law is suppose to stop insurance companies from taking advantage of you, by adding new benefits, fighting fraud, cutting costs and improving care for patients. BODY In our country there are about 45 million uninsured Americans, insurance is the one thing you don’t want to be without. Most are uninsured due to unemployed, lost of job, self-employed, or working part-time that don’t supply insurance. So who’s paying for the medical bills, most working class people cannot afford their own medical bill, that why we have insurance to pick up the coverage.
People in despared times will get creative at getting out of paying that bill. A friend told me a story once of this girl who got her husband into urgent care using their son Medicaid number and everything was paid for. I sure it was caught eventually, but that was just one case, how many others are out there. Insurance fraud is a big problem that causes our premiums and co-pays to increase. The issues with insurance is coverage, what type of coverage does the patient have, what will it cover and is it a plan that we support. INSURANCE
The number one insurance company in America today is Blue Cross and Blue Shield (BCBS). They currently insure about 3 million people with very low and affordable plans. (BCBS) BCBS of Arkansas is my plan through Wal-Mart Corporation and BCBS of Kansas City is what most patients bring to my pharmacy. Now the issues with insurance in the pharmacy, most people do not know what type of coverage they have, wether it is medical, dental, prescription or all is covered. For prescription coverage, the processor is Express Script through Medco.
(Wire) There is a difference co-pay for patents, which depends on the plan the patient chooses, but most co-pay range five dollars for generic and ten dollars for name brand. One of the biggest issues is patient that wants a ninety day supply for medication; this plan will only allow a thirty day supply at retail and a ninety day supply through mail-order. Another issue is prior authorizations claims, most are for medications that are not on the patient formulary or they need to try a less costly drug first before the insurance will pay.
Under no circumstances can we override this type of rejection without the physician speaking to the insurance first, to do so would be fraud, and then pharmacy is liable for the charges. Sometimes it is just a product that they just will not cover, like over-the-counter (OTC) products. Most if not all insurances will not covered OTC products, they are usually cheaper to get OTC anyway. MEDICAID The most common state and federally funded health insurance is Medicaid. It currently provides health coverage to about 60 million Americans.
(Medicaid) This free or low cost program you usually hear that it is for children and pregnant women, but it is also for qualified adults, people with disabilities and seniors. State law set the criteria with in federal minimum standards and mandates who is eligible, and who is not, which is based on their income, the state’s minimum income of the poverty level. (Medicaid) Children coverage is free up to the age of eighteen, and then there is co-pay between fifty cents to two dollars depending on what the retail price is. Each member on Medicaid will have their own identification number.
Newborns are allowed to use their mother’s number for up to sixty day or until they receive theirs. Most of my patients that come to my pharmacy are on Medicaid, it is mostly mothers and their children. One of the biggest issues with Medicaid is patient not covered claims. Usually because they failed to recertify with the Medicaid office those claims can be retroactive. They might have been taken off for failure to report income, that’s happen a lot when a person becomes employed prior to recertifying. That is fraud and can get you kicked off of Medicaid pending pay back or for good.
A common reject is, submit to primary payer, meaning the patient failed to either report to the Medicaid office that they no longer have primary insurance any more. Usually that happen when the parent had regular insurance, but the child was on both the insurance and Medicaid. Before Medicaid will pay anything the claim has to be submitted to the primary insurance first. Medicaid will pay for OTC medication, only if the right brand is used. There are certain brands on Medicaid formulary that they will cover, most of the time you have to call them to get the right brand or National Drug Code (NDC).
(Wire) To fill a prescription use something other than what required is fraud, and the claim will be rejected. The Center for Medicaid Services is committed to combating Medicaid provider fraud, waste and abuse. (Medicaid) the responsibility of the Medicaid Integrity Program is to review Medicaid provides activities, audit claims, identify overpayments, and educate, also eliminate and recover improper payments. (Medicaid) MEDICARE Our country’s health insurance for people age sixty-five or older is Medicare. People younger than sixty-five can qualify too, those who have disabilities, permanent kidney failure or Lou Gehrig’s disease.
(Social Security) Medicare will help with the cost of most long term care, but not all, most members buy into a supplement plan through private insurance company to cover the cost that Medicare does not also called (Medigap). Medicare has four parts, part A which covers hospital, nursing facility inpatient, home health and hospice care. Part B which covers medical for doctor services and durable supplies that are not covered by hospital insurance. Part C Medicare Advantage combines A and B which covers you choice of provider organizations and part D which covers prescription drugs.
Majority of the people that I see with Medicare are our senior elderly folks. These patients usually pick up the whole pharmacy, sometimes ten to fifteen prescriptions at a time, so it is imperative to process the claim properly. One of our biggest claim rejections with Medicare is the use of part B instead of part D when processing insulin’s and/or diabetic supplies and nebulizer supplies. They are drugs and should fall under part D, however these particular medication are considered durable medical supplies.
A prescription for insulin and/or diabetic supplies and nebulizer supplies is not valid and will not pass an audit inspection if it does not have the diagnosis code written on it and signed by the physician. (Wire) If those codes are not on the prescription and we fill it, it is considered a fraudulent claim and the pharmacy could be fined. When a patent has the supplemental or (Medigap), the common one I see is AARP. The supplemental plan is a great tool to have especially when most seniors are on a fixed income or living on noting but their SSI.
It pays for the cost of the medication that Medicare did not pay, basically splitting the co-pay in half in some cases.
CONCLUSION Insurance is a tricky web of processing the right patient to processing the right drug, there is only so much a pharmacy or provider can do legally with in the law. Medicaid has lot of benefits for those that are uninsured. Medicare is a great program for our seniors, most who are the innovator and builders of what we have today and they deserve to have affordable healthcare and not worry about how they’re going pay for next month’s medication.
Getting everyone insured is not hard, there are plenty of affordable plans to choose from, it just getting the uninsured people to get out and do it. With the Healthcare Reform Act people have to put in the effort and try. Those that relay on these insurance plans, relay on us the providers to be educated to process the claims properly and accurately. Best practices and performance standards for states to use in their fraud prevention efforts. (Medicaid).
REFERENCES: Blue Cross and Blue Shield of Kansas City, Retrieved from http://www. bluekc. com/Home.aspx Healthcare Reform in Action, Retrieved from http://www. whitehouse. gov/healthreform Medicaid. gov. Retrieved from http://www. medicaid. gov/Medicaid-CHIP-Program-Information/By-State/missouri. html Medicare. gov.
Retrieved from http://www. medicare. gov/ Social Security. gov, Retrieved from http://www. socialsecurity. gov/pubs/EN-05-10043. pdf Wal-Mart wire portal. Retrieved from www. wireportal. walt-mart. com This site you will not have access to, because it’s for Wal-Mart employees only. I had to site it, because some of my research came from that site that I printed off from work.