pbm

Day1 ======= PBM:Pharmacybenefitmanagers:isathirdpartyadministatorproviding PBM:Pharmacybenefitmanagers:isathirdpar tyadministatorprovidingservices services forthemembersenrolledforprescriptiondrugs. whoisourclient?tiger:CVSCAREMARK CVS:REtailPharmacy CAREMARK:PBM RETAILPHARMACY:WhoaretheMajorretailpharmacy CVS,Walgreen,Walmart MajorPBMinUS:caremark,medco,aetna Majorhealthinsurancecomapanies:Aetna,Cign Majorhealthinsurance comapanies:Aetna,Cigna,BCBS,AHIC...etc a,BCBS,AHIC...etc Insurance:Sharingofriskwithothers TypesofInsurance: 1.Life 2.General(HealthInsurance) 3.Reinsuarnce(Insuranceoftheinsurer):GIC: Ininsurance,therer2terminologies: 1.Insured(Member) 2.Insurer(Insurnacecompany) modeofprovidinginsuarnce: 1.Grouphealthplan 2.Individualhealthplan

whatisthedifferncebetweencopayandpatientpay? Patientpay=deductible+copay+tax(vat) Typesofcopay? 1.fixeddollarcopay 2.%copay(coinsurance) 3.mixedofabovetwo HealthInsurancePlans: 1.TraditionalIndemnity featuresoftraditionalindemnity: 1.NOPCPconcept 2.Freedomofchoice Day2: ======= 2.MCPlanisdividedinto3typesa.HMO(Healthmaintaince/management 2.MCPlanisdividedinto3typesa.HMO(Hea lthmaintaince/managementOrg) Org) b.PPO(PrefferedprovidersOrg) c.POS(PointofService)HMO+additionalservic c.POS(PointofServi ce)HMO+additionalserviceamembercanchhoseat eamembercanchhoseatthetime thetime ofservice

HMO:PCP:primarycarephysicianisthegatekeeperforthisservice isdividedintoOPENandCLOSED 1.GatheringDemographicdataandeligibilitydetailsofthecustomers 2.Calculatingtheriskexposure(Actuaries) 3.creationofproduct(Seniormarketingmanagers&admin) 4.Marketingtheproduct 5.Enrollingundersomehealthplan 6.Atthetimeoftakingtheservice,Patientcametoprovider,takingtheservi ceandpayingthepatientpaytotheproviderandcameback 7.Submittersubmitstheclaim 8.ClaimgetsProcessed 9.Amountreceiveableandpayable 10.EOB(explanationofbenefit) whatarethetypesofclaimw.r.tPharmacy? 1.retailclaim:pharmacy 2.paper/manualclaim:member 3.Mailorderclaim:online 4.Batchclaim:whenanewclientcomesforaPBM,allthehistorydatashouldb loadedintotheadjudicationengineofthatPBM.atatimeloadingiscalled batchclaim. whoaretheclientsofPBM? Ans:sponsorer-organisation,MCO,Fed&statemandates,sometimesinsuranceco mp Clienthierarchy: 1Carrier(Insurancecomp)----manyaccounts(Organisations)-------1account---manyGroups 1group----manymembers MCO:managedcareOrganisation:HMO,PPO,POS Q:whatisthedifferencebetweenunderwriting&Clearinghouse? Day3 ======= NCPDP,HIPAAunderfed&statemandates TitleI:HealthCareAccess,Portability,andRenewability: TitleIofHIPAAregulatestheavailabilityandbreadthofgrouphealthplansan dcertainindividualhealthinsurancepolicies.ItamendedtheEmployeeRetireme ntIncomeSecurityAct,thePublicHealthServiceAct, TitleIalsolimitsrestrictionsthatagrouphealthplancanplaceonbenefits forpreexistingconditions.Grouphealthplansmayrefusetoprovidebenefitsre latingtopreexistingconditionsforaperiodof12monthsafterenrollmentint heplanor18monthsinthecaseoflateenrollment.[1]However,individualsmay reducethisexclusionperiodiftheyhadgrouphealthplancoverageorhealthi nsurancepriortoenrollingintheplan.TitleIallowsindividualstoreduceth

eexclusionperiodbytheamountoftimethattheyhad"creditablecoverage"pri ortoenrollingintheplanandafterany"significantbreaks"incoverage.[2]" Creditablecoverage"isdefinedquitebroadlyandincludesnearlyallgroupand individualhealthplans,Medicare,andMedicaid.[3]A"significantbreak"incov erageisdefinedasany63dayperiodwithoutanycreditablecoverage.[4] TitleII:PreventingHealthCareFraudandAbuse;AdministrativeSimplification; MedicalLiabilityReform Theserulesapplyto"coveredentities"asdefinedbyHIPAAandtheHHS.Covered entitiesincludehealthplans,healthcareclearinghouses,suchasbillingserv icesandcommunityhealthinformationsystems,andhealthcareprovidersthattr ansmithealthcaredatainawaythatisregulatedbyHIPAA.[8][9] PertherequirementsofTitleII,theHHShaspromulgatedfiverulesregardingA dministrativeSimplification:thePrivacyRule,theTransactionsandCodeSetsR ule,theSecurityRule,theUniqueIdentifiersRule,andtheEnforcementRule. [edit]PrivacyRule AcoveredentitymaydisclosePHItofacilitatetreatment,payment,orhealthca reoperations,[14]orifthecoveredentityhasobtainedauthorizationfromthe individual.[15]However,whenacoveredentitydisclosesanyPHI,itmustmakea reasonableefforttodiscloseonlytheminimumnecessaryinformationrequiredt oachieveitspurpose.[16] ThePrivacyRulegivesindividualstherighttorequestthatacoveredentityco rrectanyinaccuratePHI.[17]Italsorequirescoveredentitiestotakereasonab lestepstoensuretheconfidentialityofcommunicationswithindividuals.[18]F orexample,anindividualcanasktobecalledathisorherworknumber,instea dofhomeorcellphonenumber. ThePrivacyRulerequirescoveredentitiestonotifyindividualsofusesofthei rPHI.CoveredentitiesmustalsokeeptrackofdisclosuresofPHIanddocument privacypoliciesandprocedures.[19]TheymustappointaPrivacyOfficialanda contactperson[20]responsibleforreceivingcomplaintsandtrainallmembersof theirworkforceinproceduresregardingPHI.[21] AnindividualwhobelievesthatthePrivacyRuleisnotbeingupheldcanfilea complaintwiththeDepartmentofHealthandHumanServicesOfficeforCivilRigh ts(OCR).[22][23]However,accordingtotheWallStreetJournal,theOCRhasal ongbacklogandignoresmostcomplaints."Complaintsofprivacyviolationshave beenpilingupattheDepartmentofHealthandHumanServices.BetweenApril200 3andNov.30,theagencyfielded23,896complaintsrelatedtomedical-privacyr ules,butithasnotyettakenanyenforcementactionsagainsthospitals,doctor s,insurersoranyoneelseforruleviolations.Aspokesmanfortheagencysays ithasclosedthree-quartersofthecomplaints,typicallybecauseitfoundnovi olationorafteritprovidedinformalguidancetothepartiesinvolved."[24] [edit]TransactionsandCodeSetsRule TheHIPAA/EDIprovisionwasscheduledtotakeeffectfromOctober16,2003with aone-yearextensionforcertain"smallplans".However,duetowidespreadconfu sionanddifficultyinimplementingtherule,CMSgrantedaone-yearextensiont oallparties.[citationneeded]OnJanuary1,2012thenewestversion5010becom eseffective,replacingtheversion4010.[25]Thisallowsforthelargerfields izeofICD-10-CMaswellasotherimprovements. AfterJuly1,2005mostmedicalprovidersthatfileelectronicallydidhavetof iletheirelectronicclaimsusingtheHIPAAstandardsinordertobepaid.[citat ionneeded] KeyEDI(X12)transactionsusedforHIPAAcomplianceare: EDIHealthCareClaimTransactionset(837)isusedtosubmithealthcareclaim billinginformation,encounterinformation,orboth,exceptforretailpharmacy claims(seeEDIRetailPharmacyClaimTransaction).Itcanbesentfromprovider sofhealthcareservicestopayers,eitherdirectlyorviaintermediarybillers

andclaimsclearinghouses.Itcanalsobeusedto transmithealthcareclaimsandbillingpaymentinformationbetweenpayerswith differentpaymentresponsibilitieswherecoordinationofbenefitsisrequiredor betweenpayersandregulatoryagenciestomonitortherendering,billing,and/o rpaymentofhealthcareserviceswithinaspecifichealthcare/insuranceindust rysegment. Forexample,astatementalhealthagencymaymandateallhealthcareclaims,Pro vidersandhealthplanswhotradeprofessional(medical)healthcareclaimselec tronicallymustusethe837HealthCareClaim:Professionalstandardtosendin claims.AstherearemanydifferentbusinessapplicationsfortheHealthCarecl aim,therecanbeslightderivationstocoveroffclaimsinvolvinguniqueclaims suchasforInstitutions,Professionals,Chiropractors,andDentistsetc. EDIRetailPharmacyClaimTransaction(NCPDPTelecommunicationsStandardversion 5.1)isusedtosubmitretailpharmacyclaimstopayersbyhealthcareprofessi onalswhodispensemedications,eitherdirectlyorviaintermediarybillersand claimsclearinghouses.Itcanalsobeusedtotransmitclaimsforretailpharmac yservicesandbillingpaymentinformationbetweenpayerswithdifferentpayment responsibilitieswherecoordinationofbenefitsisrequiredorbetweenpayersa ndregulatoryagenciestomonitortherendering,billing,and/orpaymentofreta ilpharmacyserviceswithinthepharmacyhealthcare/insuranceindustrysegment. EDIHealthCareClaimPayment/AdviceTransactionSet(835)canbeusedtomakea payment,sendanExplanationofBenefits(EOB),sendanExplanationofPayments (EOP)remittanceadvice,ormakeapaymentandsendanEOPremittanceadviceon lyfromahealthinsurertoahealthcareprovidereitherdirectlyorviaafina ncialinstitution. EDIBenefitEnrollmentandMaintenanceSet(834)canbeusedbyemployers,union s,governmentagencies,associationsorinsuranceagenciestoenrollmembersto apayer.Thepayerisahealthcareorganizationthatpaysclaims,administersin suranceorbenefitorproduct.Examplesofpayersincludeaninsurancecompany, healthcareprofessional(HMO),preferredproviderorganization(PPO),governmen tagency(Medicaid,Medicareetc.)oranyorganizationthatmaybecontractedby oneoftheseformergroups. EDIPayrollDeductedandothergroupPremiumPaymentforInsuranceProducts(820 )isatransactionsetwhichcanbeusedtomakeapremiumpaymentforinsurance products.Itcanbeusedtoorderafinancialinstitutiontomakeapaymentto apayee. EDIHealthCareEligibility/BenefitInquiry(270)isusedtoinquireabouttheh ealthcarebenefitsandeligibilityassociatedwithasubscriberordependent. EDIHealthCareEligibility/BenefitResponse(271)isusedtorespondtoareque stinquireaboutthehealthcarebenefitsandeligibilityassociatedwithasubs criberordependent. EDIHealthCareClaimStatusRequest(276)Thistransactionsetcanbeusedbya provider,recipientofhealthcareproductsorservicesortheirauthorizedage nttorequestthestatusofahealthcareclaim. EDIHealthCareClaimStatusNotification(277)Thistransactionsetcanbeused byahealthcarepayerorauthorizedagenttonotifyaprovider,recipientora uthorizedagentregardingthestatusofahealthcareclaimorencounter,orto requestadditionalinformationfromtheproviderregardingahealthcareclaimo rencounter.ThistransactionsetisnotintendedtoreplacetheHealthCareCla imPayment/AdviceTransactionSet(835)andtherefore,isnotusedforaccountp aymentposting.Thenotificationisatasummaryorservicelinedetaillevel.T henotificationmaybesolicitedorunsolicited. EDIHealthCareServiceReviewInformation(278)Thistransactionsetcanbeuse dtotransmithealthcareserviceinformation,suchassubscriber,patient,demo graphic,diagnosisortreatmentdataforthepurposeofrequestforreview,cert ification,notificationorreportingtheoutcomeofahealthcareservicesrevie w. EDIFunctionalAcknowledgementTransactionSet(997)thistransactionsetcanbe usedtodefinethecontrolstructuresforasetofacknowledgmentstoindicate theresultsofthesyntacticalanalysisoftheelectronicallyencodeddocuments.

AlthoughitisnotspecificallynamedintheHIPAALegislationorFinalRule,i tisnecessaryforX12transactionsetprocessing.Theencodeddocumentsareth etransactionsets,whicharegroupedinfunctionalgroups,usedindefiningtra nsactionsforbusinessdatainterchange.Thisstandarddoesnotcoverthesemant icmeaningoftheinformationencodedinthetransactionsets. [edit]SecurityRule TheFinalRuleonSecurityStandardswasissuedonFebruary20,2003.Ittookef fectonApril21,2003withacompliancedateofApril21,2005formostcovered entitiesandApril21,2006for"smallplans".TheSecurityRulecomplementsth ePrivacyRule.WhilethePrivacyRulepertainstoallProtectedHealthInformat ion(PHI)includingpaperandelectronic,theSecurityRuledealsspecificallyw ithElectronicProtectedHealthInformation(EPHI).Itlaysoutthreetypesofs ecuritysafeguardsrequiredforcompliance:administrative,physical,andtechni cal.Foreachofthesetypes,theRuleidentifiesvarioussecuritystandards,an dforeachstandard,itnamesbothrequiredandaddressableimplementationspeci fications.Requiredspecificationsmustbeadoptedandadministeredasdictated bytheRule.Addressablespecificationsaremoreflexible.Individualcovereden titiescanevaluatetheirownsituationanddeterminethebestwaytoimplement addressablespecifications.Someprivacyadvocateshavearguedthatthis"flexib ility"mayprovidetoomuchlatitudetocoveredentities.[26]Thestandardsand specificationsareasfollows:AdministrativeSafeguardspoliciesandprocedure sdesignedtoclearlyshowhowtheentitywillcomplywiththeact oCoveredentities(entitiesthatmustcomplywithHIPAArequirements)mustadop tawrittensetofprivacyproceduresanddesignateaprivacyofficertoberesp onsiblefordevelopingandimplementingallrequiredpoliciesandprocedures. oThepoliciesandproceduresmustreferencemanagementoversightandorganizati onalbuy-intocompliancewiththedocumentedsecuritycontrols. oProceduresshouldclearlyidentifyemployeesorclassesofemployeeswhowill haveaccesstoelectronicprotectedhealthinformation(EPHI).AccesstoEPHI mustberestrictedtoonlythoseemployeeswhohaveaneedforittocompleteth eirjobfunction. oTheproceduresmustaddressaccessauthorization,establishment,modification, andtermination. oEntitiesmustshowthatanappropriateongoingtrainingprogramregardingthe handlingofPHIisprovidedtoemployeesperforminghealthplanadministrativef unctions. oCoveredentitiesthatout-sourcesomeoftheirbusinessprocessestoathirdp artymustensurethattheirvendorsalsohaveaframeworkinplacetocomplywit hHIPAArequirements.Companiestypicallygainthisassurancethroughclausesin thecontractsstatingthatthevendorwillmeetthesamedataprotectionrequir ementsthatapplytothecoveredentity.Caremustbetakentodetermineifthe vendorfurtherout-sourcesanydatahandlingfunctionstoothervendorsandmoni torwhetherappropriatecontractsandcontrolsareinplace. oAcontingencyplanshouldbeinplaceforrespondingtoemergencies.Coverede ntitiesareresponsibleforbackinguptheirdataandhavingdisasterrecoveryp roceduresinplace.Theplanshoulddocumentdatapriorityandfailureanalysis, testingactivities,andchangecontrolprocedures. oInternalauditsplayakeyroleinHIPAAcompliancebyreviewingoperationswi ththegoalofidentifyingpotentialsecurityviolations.Policiesandprocedure sshouldspecificallydocumentthescope,frequency,andproceduresofaudits.A uditsshouldbebothroutineandevent-based. oProceduresshoulddocumentinstructionsforaddressingandrespondingtosecur itybreachesthatareidentifiedeitherduringtheauditorthenormalcourseof operations.PhysicalSafeguardscontrollingphysicalaccesstoprotectagainst inappropriateaccesstoprotecteddata oControlsmustgoverntheintroductionandremovalofhardwareandsoftwarefro mthenetwork.(Whenequipmentisretireditmustbedisposedofproperlytoens urethatPHIisnotcompromised.) oAccesstoequipmentcontaininghealthinformationshouldbecarefullycontroll edandmonitored.

oAccesstohardwareandsoftwaremustbelimitedtoproperlyauthorizedindivid uals. oRequiredaccesscontrolsconsistoffacilitysecurityplans,maintenancerecor ds,andvisitorsign-inandescorts. oPoliciesarerequiredtoaddressproperworkstationuse.Workstationsshouldb eremovedfromhightrafficareasandmonitorscreensshouldnotbeindirectvi ewofthepublic. oIfthecoveredentitiesutilizecontractorsoragents,theytoomustbefully trainedontheirphysicalaccessresponsibilities.TechnicalSafeguards controll ingaccesstocomputersystemsandenablingcoveredentitiestoprotectcommunic ationscontainingPHItransmittedelectronicallyoveropennetworksfrombeingi nterceptedbyanyoneotherthantheintendedrecipient. oInformationsystemshousingPHImustbeprotectedfromintrusion.Wheninforma tionflowsoveropennetworks,someformofencryptionmustbeutilized.Ifclos edsystems/networksareutilized,existingaccesscontrolsareconsideredsuffic ientandencryptionisoptional. oEachcoveredentityisresponsibleforensuringthatthedatawithinitssyste mshasnotbeenchangedorerasedinanunauthorizedmanner. oDatacorroboration,includingtheuseofchecksum,double-keying,messageaut hentication,anddigitalsignaturemaybeusedtoensuredataintegrity. oCoveredentitiesmustalsoauthenticateentitieswithwhichtheycommunicate. Authenticationconsistsofcorroboratingthatanentityiswhoitclaimstobe. Examplesofcorroborationinclude:passwordsystems,twoorthree-wayhandshakes ,telephonecallback,andtokensystems. oCoveredentitiesmustmakedocumentationoftheirHIPAApracticesavailableto thegovernmenttodeterminecompliance. oInadditiontopoliciesandproceduresandaccessrecords,informationtechnol ogydocumentationshouldalsoincludeawrittenrecordofallconfigurationsett ingsonthecomponentsofthenetworkbecausethesecomponentsarecomplex,conf igurable,andalwayschanging. oDocumentedriskanalysisandriskmanagementprogramsarerequired.Covereden titiesmustcarefullyconsidertherisksoftheiroperationsastheyimplements ystemstocomplywiththeact.(Therequirementofriskanalysisandriskmanage mentimpliesthattheactssecurityrequirementsareaminimumstandardandplace sresponsibilityoncoveredentitiestotakeallreasonableprecautionsnecessar ytopreventPHIfrombeingusedfornon-healthpurposes.) [edit]UniqueIdentifiersRule(NationalProviderIdentifier) HIPAAcoveredentitiessuchasproviderscompletingelectronictransactions,hea lthcareclearinghouses,andlargehealthplans,mustuseonlytheNationalProvi derIdentifier(NPI)toidentifycoveredhealthcareprovidersinstandardtransa ctionsbyMay23,2007.SmallhealthplansmustuseonlytheNPIbyMay23,2008 . EffectivefromMay2006(May2007forsmallhealthplans),allcoveredentities usingelectroniccommunications(e.g.,physicians,hospitals,healthinsurancec ompanies,andsoforth)mustuseasinglenewNPI.TheNPIreplacesallotherid entifiersusedbyhealthplans,Medicare(i.e.,theUPIN),Medicaid,andotherg overnmentprograms.However,theNPIdoesnotreplaceaprovider'sDEAnumber,s tatelicensenumber,ortaxidentificationnumber.TheNPIis10digits(maybe alphanumeric),withthelastdigitbeingachecksum.TheNPIcannotcontainany embeddedintelligence;inotherwords,theNPIissimplyanumberthatdoesnot itselfhaveanyadditionalmeaning.TheNPIisuniqueandnational,neverre-use d,andexceptforinstitutions,aproviderusuallycanhaveonlyone.Aninstitu tionmayobtainmultipleNPIsfordifferent"subparts"suchasafree-standingc ancercenterorrehabfacility. [edit]EnforcementRule OnFebruary16,2006,HHSissuedtheFinalRuleregardingHIPAAenforcement.It becameeffectiveonMarch16,2006.TheEnforcementRulesetscivilmoneypenalt iesforviolatingHIPAArulesandestablishesproceduresforinvestigationsand hearingsforHIPAAviolations;however,itsdeterrenteffectsseemtobenegligi blewithfewprosecutionsforviolations.[27]Wikisourcehasoriginaltextrelat

edtothisarticle:AmericanRecoveryandReinvestmentActof2009/DivisionA/Ti tleXIII/SubtitleD [edit]HITECHAct:PrivacyRequirements SubtitleDoftheHealthInformationTechnologyforEconomicandClinicalHealth Act(HITECHAct),enactedaspartoftheAmericanRecoveryandReinvestmentAct of2009,andaddressestheprivacyandsecurityconcernsassociatedwiththeel ectronictransmissionofhealthinformation. ThissubtitleextendsthecompletePrivacyandSecurityProvisionsofHIPAAtob usinessassociatesofcoveredentities.Thisincludestheextensionofnewlyupd atedcivilandcriminalpenaltiestobusinessassociates.Thesechangesarealso requiredtobeincludedinanybusinessassociateagreementswithcoveredentit ies.OnNovember30,2009,theregulationsassociatedwiththenewenhancements toHIPAAenforcementtookeffect.[28] AnothersignificantchangebroughtaboutinSubtitleDoftheHITECHAct,isthe newbreachnotificationrequirements.Thisimposesnewnotificationrequirement soncoveredentities,businessassociates,vendorsofpersonalhealthrecords( PHR)andrelatedentitiesifabreachofunsecuredprotectedhealthinformation (PHI)occurs.OnApril27,2009,theDepartmentofHealthandHumanServices(HH S)issuedguidanceonhowtosecureprotectedhealthinformationappropriately.[ 29]BothHHSandtheFederalTradeCommission(FTC)wererequiredundertheHITE CHActtoissueregulationsassociatedwiththenewbreachnotificationrequirem ents.TheHHSrulewaspublishedintheFederalRegisteronAugust24,2009,[30] andtheFTCrulewaspublishedonAugust25,2009.[31] ThefinalsignificantchangemadeinSubtitleDoftheHITECHAct,implementsne wrulesfortheaccountingofdisclosuresofapatient'shealthinformation.It extendsthecurrentaccountingfordisclosurerequirementstoinformationthati susedtocarryouttreatment,paymentandhealthcareoperationswhenanorgani zationisusinganelectronichealthrecord(EHR).Thisnewrequirementalsolim itsthetimeframefortheaccountingtothreeyearsinsteadofsixasitcurrent lystands.Thesechangeswon'ttakeeffectuntilJanuary1,2011,fororganizati onsimplementingEHRsbetweenJanuary1,2009andJanuary1,2011,andJanuary1 ,2013,fororganizationswhohadimplementedanEHRpriortoJanuary1,2009. [edit]Effectsonresearchandclinicalcare TheenactmentofthePrivacyandSecurityRuleshascausedmajorchangesinthe wayphysiciansandmedicalcentersoperate.Thecomplexlegalitiesandpotential lystiffpenalties associatedwithHIPAA,aswellastheincreaseinpaperworkandthecostofits implementation,werecausesforconcernamongphysiciansandmedicalcenters.An August2006articleinthejournalAnnalsofInternalMedicinedetailedsomesu chconcernsovertheimplementationandeffectsofHIPAA.[32] [edit]Effectsonresearch HIPAArestrictionsonresearchershaveaffectedtheirabilitytoperformretrosp ective,chart-basedresearchaswellastheirabilitytoprospectivelyevaluate patientsbycontactingthemforfollow-up.AstudyfromtheUniversityofMichig andemonstratedthatimplementationoftheHIPAAPrivacyruleresultedinadrop from96%to34%intheproportionoffollow-upsurveyscompletedbystudypatie ntsbeingfollowedafteraheartattack.[33]Anotherstudy,detailingtheeffect sofHIPAAonrecruitmentforastudyoncancerprevention,demonstratedthatHI PAA-mandatedchangesledtoa73%decreaseinpatientaccrual,atriplingoftim espentrecruitingpatients,andatriplingofmeanrecruitmentcosts.[34] Inaddition,informedconsentformsforresearchstudiesnowarerequiredtoinc ludeextensivedetailonhowtheparticipant'sprotectedhealthinformationwill bekeptprivate.Whilesuchinformationisimportant,theadditionofalengthy ,legalisticsectiononprivacymaymakethesealreadycomplexdocumentsevenle ssuser-friendlyforpatientswhoareaskedtoreadandsignthem. ThesedatasuggestthattheHIPAAprivacyrule,ascurrentlyimplemented,maybe havingnegativeimpactsonthecostandqualityofmedicalresearch.Dr.KimEa gle,professorofinternalmedicineattheUniversityofMichigan,wasquotedin theAnnalsarticleassaying,"Privacyisimportant,butresearchisalsoimpor tantforimprovingcare.Wehopethatwewillfigurethisoutanddoitright."[

32] [edit]Effectsonclinicalcare ThecomplexityofHIPAA,combinedwithpotentiallystiffpenaltiesforviolators ,canleadphysiciansandmedicalcenterstowithholdinformationfromthosewho mayhavearighttoit.AreviewoftheimplementationoftheHIPAAPrivacyRul ebytheU.S.GovernmentAccountabilityOfficefoundthathealthcareproviders were"uncertainabouttheir[legal]privacyresponsibilitiesandoftenresponded withanoverlyguardedapproachtodisclosinginformation...thannecessarytoe nsurecompliancewiththePrivacyrule".[32]Reportsofthisuncertaintycontinu e.[35] [edit]Costsofimplementation IntheperiodimmediatelypriortotheenactmentoftheHIPAAPrivacyandSecuri tyActs,medicalcentersandmedicalpracticeswerechargedwithgetting"intoc ompliance".Withanearlyemphasisonthepotentiallyseverepenaltiesassociate dwithviolation,manypracticesandcentersturnedtoprivate,for-profit"HIPA Aconsultants"whowereintimatelyfamiliarwiththedetailsofthelegislation andofferedtheirservicestoensurethatphysiciansandmedicalcenterswerefu lly"incompliance".Inadditiontothecostsofdevelopingandrevampingsystem sand practices,theincreaseinpaperworkandstafftimenecessarytomeetthelegal requirementsofHIPAAmayimpactthefinancesofmedicalcentersandpracticesa tatimewheninsurancecompanyandMedicarereimbursementisalsodeclining.

AccumulatorComponentCode-indicateswhatdollarswillbeaccumulatedasindic atedinthisfieldOption29PlanBenefit(RxCLAIM)Validvaluesare: 1=Deductible 2=Deductible+Copay 3=PatientPay 4=PatientPay(AfterAdjDate) 5=PostDeductible 6=PostDeductible+Copay 7=PostPatientPay 8=PostPatientPay(AfterAdjDate) 9=PostDeductible(AfterAdjDate) A=PostCopay B=PostCopay+ProductSelectionPenalty C=PostDeductible+Copay+ProductSelectionPenalty D=PostCopay(AfterAdj.Date) Day4 ======= BankIdentificationNumber(BIN)EachPBMplatformhastheirownBINnumber.Th isisusedbytheswitchingstationtosendthetransactiontothecorrectPBMp latform.CVSCaremarksBINnumbersare:   

QL=610029 RECAP=610415 RxCLAIM=004336

BatchClaimTheprocessbywhichagroupofprocessedclaimsneedtoloaded.It arrivesintheformofsequentialfilesthatmaybesourcedfromaclientorag overnmentagency/vendor.ItcanbeusedwhenanewclientcomesintoCaremarkan dneedstoloadhistoricalclaimdata.Itisalsousedwhenagroupofclaimsn eedtobereversedandresubmitted(R&R)inordertocorrectsomethingonthecl aimduetovolume

strategies/FunctionalitiesofPBM: 1.CreateandmaintainFormulary 2.Tiercopay 3.GenericSubstitution 4.Manufacturerdiscount 5.RetailPharmacyrebate 6.Priorauthorisation 7.DUR 8.Mailorderpharmacy drugcoverage:whatrtypeofdrugsshouldbecoveredismentionedintheplan. pharmacistneedsauthorisationinordertodispencethatparticularfromthecar rier/inthedatabaseofPBM Formulary:itisalistofapproveddrugsbyFDA. P&Tcommmitte:Pharmateucal&Therapeuticcommiittee:createstheformularybase dontheeffectiveness,safenessandcostofthedrugs. EachishavingtheirseparateP&Tcommitte thememberofP&TincludesthetheboardofdirectorsofPBM,providers,speciali sts. BasedonthefeedbackofDUR,DDItheydesigntheformualry FRC:Formularyreviewcommittee:reviewstheformulary FDA:Food&DrugAdmin:undertheFEDgovt typesofdrugs: 1.Formulary 2.Nonformulary howmanyoftypesofformulary: 1.OPen:bothformandnonformdrugsshouldbeincludedinthis 2.closed:memberisrestrictedonlytotheformdrugs 3.Mixed/managed: DUR:Drugutilisationreview:theextentadrugisutilisedbythepatientorpr escribedbytheprescriber DDI:drugtodruginteraction. accordingtoFormulary,drugsrcategorisedinto3types: 1.Generic:tier1:copayisleast 2.Prefferedbrand:tier2ismorethattier1 3.Nonprefferedbrand:tier3ishavinghighestcopay Drugsrcomingfromthe3sources: 1.FDB:Firstdatabank 2.Micromedix 3.Medispan QL:quantumleap RECAP:remoteelectronicclaimadjudicationprocess PDL:preffereddruglist(Thisreferstomedicationsthatmaybeonaformulary inamultipletierbenefitdesignthatallowsforco-paymentatthetimeofserv iceequaltothatchargedforsecond-tierormidlevelcost.Forexample,apati entwouldpaythenexthighestco-paymentforthepreferreddrugafterthegener

icco-paymentamount,notthehighestco-paymentoverallinthebenefitplan) DAW:dispenceaswritten(Anorderonaprescriptioncommandingthepharmacistt oprovidetherecipientwiththeprescriptionexactlyasitwaswritten) GPI:genericproductidentifier:RxClaim(Afourteendigithierarchicalnumber thatisusedtoclassifydrugsintotherapeuticcategories.OneGPImayberela tedtomanyNDCIds.Onlyonenumberpergeneric,coversallformsofthedrug,t herapeuticclassificationschemefordruginteraction&allergycheckingandpla nedits) NDC:nationaldrugcode:RxClaim,REcap GCN:genericcodenumber:Recap(Non-unique,TheGenericCodeNumber(GCN)is arandomnumberrepresentingthegenericformulation.TheGCNisspecifictog enericingredientcombination,routeofadministration,dosageformanddrugstr ength.TheGCNisthesameforallmanufacturersand/orpackagesizes) AWP:averagewholesaleprice ARP:averageretailprice ========================================================================= GeneralInfo: Someconsumerdrivenhealthcareplans: 1.DiscountDrugCard:Discountdrugcardsofferdiscountsonvariousme dicalservicesincludingmedicine.Theyarenotaformofinsurance.Somearefr eewhileothersmayinvolveaheftyfee.Theyareofferedbystategovernments, drugcompanies,non-profitandfor-profitbusinesses. 2.HealthSpendingAccount:Ahealthsavingsaccount(HSA),isatax-ad vantagedmedicalsavingsaccountavailabletotaxpayersintheUnitedStateswho areenrolledinaHighDeductibleHealthPlan(HDHP)(Ahigh-deductiblehealth plan(HDHP)isahealthinsuranceplanwithlowerpremiumsandhigherdeductible sthanatraditionalhealthplan.). Employer-fundedplansthatreimburseemployeesforincurredmedicalexpensestha tarenotcoveredbythecompany'sstandardinsuranceplan.Becausetheemployer fundstheplan,anydistributionsareconsideredtaxdeductible(totheemploye r).Reimbursementdollarsreceivedbytheemployeearegenerallytaxfree. 3.IRA:Anindividualretirementarrangement(IRA)isaformofretireme ntplan(Thetermsretirementplanorsuperannuationrefertoapensiongranted uponRetirementplansmaybesetupbyemployers,insurancecompanies,thegover nmentorotherinstitutionssuchasemployerassociationsortradeunions)that providestaxadvantagesforretirementsavingsintheUnitedStates.Thetermen compassesanindividualretirementaccountatrustorcustodialaccountsetupf ortheexclusivebenefitoftaxpayersortheirbeneficiariesandanindividualr etirementannuity,bywhichthetaxpayerspurchaseanannuitycontractoranend owmentcontractfromalifeinsurancecompany. 4.HRA:HealthReimbursementAccountsorHealthReimbursementArrangemen ts(HRAs)areInternalRevenueService(IRS-TheIRSisresponsibleforcollecti ngtaxesandtheinterpretationandenforcementoftheInternalRevenueCode.)-s anctionedprogramsthatallowanemployertosetasidefundstoreimbursemedica lexpensespaidbyparticipatingemployees.UsinganHRAyields"taxadvantages tooffsethealthcarecosts"forbothemployeesaswellasanemployer. 5.FSA:Aflexiblespendingaccount(FSA),alsoknownasaflexiblespen dingarrangement,isoneofanumberoftax-advantagedfinancialaccountsthatc anbesetupthroughacafeteriaplan(Acafeteriaplanisatypeofemployeebe nefitplanofferedintheUnitedStatespursuanttoSection125oftheInternal RevenueCode.)ofanemployerintheUnitedStates.AnFSAallowsanemployeeto setasideaportionofhisorherearningstopayforqualifiedexpensesasest ablishedinthecafeteriaplan,mostcommonlyformedicalexpensesbutoftenfor dependentcareorotherexpenses.Moneydeductedfromanemployee'spayintoan FSAisnotsubjecttopayrolltaxes,resultinginsubstantialpayrolltaxsavin gs.OnesignificantdisadvantagetousinganFSAisthatfundsnotusedbythee ndoftheplanyeararelosttotheemployer.[1]

SometerminologiesrelatedtoPricingofdrugs: 

MaximumOut-of-Pocket(Max.Out-of-PocketorMOOP) Themaximumout-of-pocketisthelimit,orceiling,onyourcostsformedicalca rewithintheinsuranceplanyear.OncetheapplicableYearlyout-of-pocketmaxi mumisreached,youpaynothingforcoveredprescriptiondrugsfortheremainder ofthecalendaryear. 

MaximumRxOut-of-Pocket ThemaximumRxout-of-pocketisthelimit,orceiling,onyourcostsforprescri ptionswithintheinsuranceplanyearorforagivenprescription.Thismaximum mayvarybyprescriptiontierorlevel. AverageWholesalePrice(AWP)Theaverageormostcommonpricearetail

pharmacywouldpayawholesalertobuyaspecificquantityofadrug.Itisthe compositewholesalepricechargedonaspecificcommodity.ItisalwaysanOver ??????amountofAAC. IngredientCost:Totalcostoftheindividualelementsusedinpreparing

thedrug DispensingFee:Theamountpaidtoapharmacyfordistributingeachmedi

cationinadditiontothemedicationingredientcost. PatientPay:Thisisthetotalamountpaidbythepatienti.e.sumofco

pay+deductible+someadditionaltax WithholdAmount:Withholdsareamountsheldbackfromapharmacyatthe

timeofpayment,andgivenbackatalaterdate,perhapsforcompliancepurposes oradministrativefees,forexample.Enteraflatdollaramounttowithhold,e. g..12=$0.12 Deductibles:Theamountspecifiedineachplandesignthatamembermus

tpayoutofpocketbeforebecomingeligibletouseplanbenefits.Afterthede ductibleismet,playco-payments(ifany)willapply ActualAcquisitionCost(AAC)Thepriceapharmacyactuallypaysforad

rug.Thenetpaymentbyapharmacytopurchaseamedicationafterallowances,d iscountsorrebates. AdministrationFeesAphysicianschargesforinjectingoradministeringa

drug. AdministrativeCostsCostsincurredbyaproviderorinsuranceorganizat

ionforservicessuchasoverhead,billingandclaimsprocessingexpense,andot hermanagementservicesrelatedtothedeliveryofhealthcareservices. AllowableChargeThemaximumfee(charge)allowedforpaymenttoaprov

ider. MaximumAllowableCost(MAC)Thisisanupperlimitpricethataninsure

rorhealthplanwillreimburseforgenericallyavailableormultiplesourcemed ications.ThistypicallyfollowstheinitiativeforreimbursementbytheMedica reandMedicaidprogramwhenmorethantwogenericdrugsareavailableinthema rketplace. CCW-CaremarkCalculatedWAC.ThispriceissetbyCVSCaremarktobeu

sedforthosedrugsthatdonothaveaWACprice.WhenaclientelectstouseWA CpricingwewillalsosetupCCW.WhenadrugwithnoWACpriceissubmittedth eCCWpricewillbeusedinthecalculationtopricetheclaims. U&CUsualandCustomaryisthelowestpricethepharmacywouldcharge

ifthecustomerwerepayingcashforanidenticalprescriptiononthatparticula rday.Thispricemustincludeanyapplicablediscountsofferedbythepharmacy toattractcustomers. WAC-Themanufacturerchargesthisamounttothewholesaler(pharmacy)

topurchasethedrug.Itisapublishedpriceanddoesnotgenerallyreflectany rebatesordiscounts.Itisoftenreferredtoasthecatalogueprice.NotallN DCshaveaWACprice. InsuranceInformation:HMO/PPOProviderList FollowingisalistoftheHMOsandPPOsacceptedbytheDepartmentofOphthalmo logyandVisualSciencesClinics.Theclinicswillalsoseepatientsonafee-fo r-servicebasis. Ifyouhaveanyquestionsaboutyourinsurancecoverage,pleasecontactyourins uranceproviderdirectly. Type OrganizationName PPO ADMAR(formallyPrincipalPPO) HMO ADVOCATEHEALTHPARTNERS HMO/POS AETNAHMO/POS-UIC HMO/POS AETNAHMO(HMO/QPOS) POS AETNAPOS(ElectChoiceandManagedChoice) PPO AETNAPPO/EPO(OpenChoiceandTraditional) HMO AMERIGROUPILLINOIS,INC PCPCAP-MILESQUAREONLY PPO BEECHSTREETPPO PPO BLUECROSSBLUESHIELD(BC/BS)PPO MedicareSelect BC/BSMEDICARESELECT POS BC/BSBLUECHOICE StudentProgram CAMPUSCARE PPO CARLECAREPPO(FORMERLYHEALTHALLIANCEPPO) PPO CCN/EPIQUAL HMO CIGNA HMO POS CIGNA POS PPO CIGNASTATEOFIL(QCHP) WC CORVEL/ CORCARE PPO EVOLUTIONSHEALTHCARESYSTEMS PPO FIRST HEALTH PPO GIA-GROUPINSURANCEADM GLOBAL GLOBAL/PACKAGECONTRACTS HMO HARMONYHEALTHPLAN(Commercial) HMO HARMONYHEALTHPLAN(Medicaid) PCPCAP-MILESQUAREONLY HMO HEALTHALLIANCEHMO PPO HEALTHMARKETINGINCPPO PPO HEALTHNETWORKPPO/WELLMARK PPO HFN-HEALTHCARE'SFINESTNETWORK EPO HFN-HEALTHCARE'SFINESTNETWORKEPO HMO HMOILL-UIC(SITE141) HMO HMO-ILLINOIS HMO/EPO HUMANANATIONALHMO POS HUMANA POS HMO HUMANAHMO-UIC HMO HUMANA HMO HMO HUMANA ACCESS PPO HUMANA PPO

MedicareSelect JBCPLATINUM MedicareSelect JBCGOLD PPO MULTIPLAN HMO/PPO NOTCONTRACTEDHMOorPPO PPO PNA-PREFERREDNETWORKACCESS PPO PPONEXT PPO PREFERRED PLAN PPO PRIVATEHEATLHCARESYSTEMS(PHCS) PPO SAGAMOREHEALTHNETWORK PPO THREERIVERSPROVIDERNETWORK HMO UNICARE HMO HMO UNICARE(formerlyRUSHPRUDENTIAL)HMO-UIC POS/PPO UNICAREPOS/PPO HMO UNIONHEALTHSERVICE HMO UNIONMEDICALCENTER PSYCH UNITEDBEHAVIORALHEALTH HMO/PPO/POS UNITEDHEALTHCARE(formerly:CHICAGOHMO) PPO UNITEDOPENACCESS HMO UNITEDMEDICAIDHMO-UIC UnitedMedicaidHMO=UICClinicSite:372=MileSquare HMO UNITEDHEALTHCAREMEDICAID TRANSPLANT UNITEDRESOURCENETWORK