Patient Services Solutions

You likely know the name of your private insurance carrier and you may even know the name of your employer's worker's compensation insurance carrier--but what you may not know is that these insurance carriers have little to do with your actual claims.  Instead of doing the back-office work themselves, they contract with Third Party Administrators, or TPAs.  TPAs are responsible for a wide number of tasks. They may conduct Utilization Reviews for medication and medical procedures and issues authorizations or denials. They may handle pharmacy benefits, or contract directly with the pharmacy benefit managers (PBMS) that process the pharmacy claims. They handle all billing for medical providers, and pay those providers based on contractual agreements. The TPA may have complete control over every financial aspect of your private insurance or worker's compensation claim. Sedgwick or United Healthcare may be your insurance carrier in name only.  Insurance carriers contract with TP

 Pharmacy Benefit Managers coordinate between pharmacies, insurance carriers, and other third party administrators in order to  guarantee payment and process pharmacy claims. Pharmacy Benefit Managers are shortened to PBMs, and the number of claims processed by PBMs have grown exponentially in the past decade.  In fact, a PBM probably is responsible for processing the medications your doctor writes every month. And yet, you probably don't even know the name of the company that touches every one of your claims and stores your personal health information (PHI). Although PBMs are engaged in processing your medication they do not work for the patient and they have no interest in the standard of your healthcare.  The three largest PBMs in the industry are CVS Caremark, Cigna (Express Scripts), and United Health Group (OptumRX). These PBMs handle private insurance, medicare, worker's compensation, and auto no-fault.  Drugchannels.net estimates for 2020 ...The big three PBMs—CVS Heal

 

Communication is key in any successful relationship but it's especially important in the world of healthcare.  Patients are at the center of a complicated web of providers, insurance carriers, third party administrators, pharmacy benefit managers, claim adjusters, and federal regulation.  The meeting between a patient and their trusted doctor is only the beginning of a long and complicated journey.  Imagine a common healthcare scenario, such as a doctor's visit for a sore shoulder or an infected cut.  The meeting may last no more than fifteen minutes, but it sets off a complicated chain of events, navigating a system of payee/payor relationships, medical providers, and information processors. In the case of an infected cut, the doctor prescribes two antibiotics, a pill and an ointment, and electronically transmits prescriptions to the pharmacy on file.  A new provider--the pharmacist--has just been invited to the relationship. Here a new series of complications is introduced: i