Patient Services Solutions

 Throughout your life, you will change insurance carriers many times. Sometimes you lose or gain eligibility due to a career change. You may age into Medicare eligibility, you may marry or divorce, may choose to join a plan on the Healthcare Exchange, or may become disabled and eligible for your state's Medicaid or Social Security benefits. Depending on the type of insurance, you may be able to change your plan every year, or you may have to wait until you have a qualifying life event.  Each time your benefits change, you are faced with the same series of questions and considerations. Is your regular physician in your new network? Do you need to get a new referral to continue to see your allergist or cardiologist? Will your deductible be higher or lower? Are your medications still covered? What is your new copay for regular visits? Can you go to the emergency room if if it's necessary?  First it's necessary to understand the difference between an in-network provider (INN) a

 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

If you are dealing with a work-related injury, an ongoing health issue, or simply your family's standard medical needs, you probably receive a lot of paperwork. Some of it isn't easy to understand, and sometimes it's not clear if what you received is a bill for services.  Explanation of Benefits (EOB) are statements from the insurance carrier regarding every item billed by a provider. For example, you may go see your primary care physician for an infected finger, but while you're there you may also discuss your current medications, and have your sinuses checked for polyps. Each separate procedure will be submitted to the insurance carrier with a medical billing code, and the insurance carrier decides based on those codes what and how much to pay.   Those are the codes that will appear on your Explanation of Benefits. At the bottom of the statement, normally in small print, there will be a legend defining each code. Sometimes those codes are easy to understand--maybe one

 

Pharmacy Benefit Manager (PBM ): Third party companies such as OptumRX, ExpressScripts, and CVS Scripts that contract with insurance carriers and coordinate with pharmacies to process pharmacy benefit claims.  The Big Three process over 70% of pharmacy insurance claims in the United States and they they are not obligated to ensuring patient care or maintaining the standard of care. They promise to reduce costs to insurance carriers and profit from minimizing care to patients. Third Party Administrators (TPA) : Third party companies that are contracted with insurance carriers to administer claims, including adjust and adjudicate, guarantee payment, utilization reviews of medical and pharmacy authorizations, contract with providers, and accept or deny liability.  Claims: Payment requests from medical providers or pharmacies submitted to the responsible party.  Responsible Party : The responsible party for a claim is the person or entity legally obligated to provide payment for services

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