Tuesday, September 14, 2010

Administration of Complex Drug Benefit Designs NCPDP

Administration of Complex Drug Benefit Designs NCPDP

  • Tiered Copay
  • Proliferation of Prescription Drug Plans
  • Drug Utilization Review – movement to perform concurrent reviews and not just reports.
  • How to Administer Drug Benefit Limitations & Formularies?


Industry Needed a “Real Time” Drug Claim Transaction

  • Verify Eligibility at Point-of-Sale
  • Verify Plan Design
  • Check for Early Refills, Drug Interactions, Therapeutic Duplication
  • Lower Administrative Transaction Costs
  • Improved Pharmacy Cash Flow


Advantages of Real Time Rx Claims Transaction

  • Concurrent DUR and management possible.
  • Technically, data can reside within health plan’s system within 24 hours.
  • Early warning flag for upcoming medical claims.
  • Could signal the beginning of an “episode of care.”
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Medicare physician fee schedule - Quick overview

Medicare Part B pays for physician services based on the PFS, which lists the more than 7,400 unique
covered services and their payment rates. Physicians’ services include the following:

* Office visits;
* Surgical procedures;
* Anesthesia services; and
* A range of other diagnostic and therapeutic services.


Medicare Physician Fee Schedule Payment Rates

Payment rates for an individual service are based on
three components:
1) Relative Value Units (RVU)
2) Conversion Factor (CF)
3) Geographic Practice Cost Indices (GPCI)


Medicare Physician Fee Schedule Payment Rates Formula


The Medicare PFS payment rates formula is shown below:

[(Work RVU x Work GPCI) + (PE RVU x PE GPCI) +
(MP RVU x MP GPCI)] x CF

Medicare fee schedule download