Pharmacists' Support: Pharmacy Techs And Insurance Billing

Pharmacy technicians work closely with licensed pharmacists to meet patients' needs. They are a vital part of the pharmacy team, and their responsibilities include processing medication requests and prescriptions, as well as helping patients to understand their insurance benefits. Pharmacy billing refers to the process of sending a prescription to a pharmacy, which then bills the patient's drug insurance and dispenses the medication. Pharmacy technicians are involved in this process, as they often help with prior authorizations and billing for health systems, insurance companies, and pharmacies. They also have a working knowledge of prescriptions and medical insurance, allowing them to confidently check every detail for accuracy. Additionally, they may need to process insurance claims forms and help complete prior authorizations with insurance companies. While pharmacy technicians have restrictions on what they can tell patients about insurance coverage, they can explain the scope and extent of their insurance benefits and provide pre-approved advice or recommendations.

Pharmacy techs' role in medical insurance billing

Pharmacy technicians work closely with licensed pharmacists to meet patients' needs. They are a vital part of the pharmacy team and have a working knowledge of prescriptions and medical insurance. They are often involved in processing insurance claims forms and helping to complete prior authorizations with insurance. They may also be involved in billing and are expected to know how to bill the companies responsible for prescription reimbursement.

Pharmacy techs play a crucial role in facilitating patient access to necessary medications. They endure hold times and navigate the complexities of dealing with health insurance companies. This includes understanding the intricacies of processing claims and payments, as well as communicating with prescriber offices about patient care. Each time a prescription is filled, a claim is made, and payment is confirmed.

Techs encounter various utilization management and coverage determinations, such as drug tiers, formularies, quantity limits, prior authorization, and step therapy. They are often the ones explaining these concepts to patients, providing advice, recommendations, or information pre-approved by the insurance company. Pharmacy techs serve as patient advocates, helping them navigate the complexities of insurance and ensuring they obtain their medications in a timely manner.

Additionally, pharmacy techs may refer patients to their medical insurance providers or offer private payment options if insurance limitations cannot be accepted or understood by the patient. They also maintain detailed records, ensuring confidentiality and protecting the security of patient information.

Overall, the role of pharmacy techs in medical insurance billing is essential for helping patients access their medications and navigate the complex healthcare system. They serve as a bridge between patients and insurance companies, providing crucial support and guidance throughout the process.

Pharmacy billing vs. medical billing

Pharmacy billing and medical billing are two different processes with distinct steps and outcomes. This section will outline the key differences between the two and explain the roles and responsibilities of those involved.

Pharmacy Billing

Pharmacy billing refers to the process of sending a prescription to a pharmacy, which then bills the patient's drug insurance and dispenses the medication. This can be done by providing the patient with a prescription to be filled at a pharmacy or by the provider's office sending the prescription to the pharmacy, which then bills and collects payment. Pharmacy billing simplifies the workflow for clinics and providers, saving them time and effort in handling billing and prior authorisations. It also allows eligible patients to use co-pay or free-trial cards to reduce their out-of-pocket expenses. Additionally, it gives pharmacists the opportunity to double-check for drug interactions, dosing, and the suitability of the therapy.

However, pharmacy billing increases the risk of temperature excursions and waste. Most specialty medications have specific storage requirements, such as refrigeration, and if the patient receives and stores the medication at home, there is a higher chance of temperature excursions. If the patient requires a therapy or dose change, the medication must be discarded, resulting in waste.

Medical Billing

Medical billing, on the other hand, is when a provider's office bills the patient's medical insurance for a drug and then purchases it through a drug distributor or pharmacy. This process can be more profitable for the provider's office but comes with added administrative time and the cost of purchasing and storing expensive medications. Medical billing gives providers the opportunity to earn additional revenue by shopping around for lower prices on medications. It also prevents patients from having to receive and transport the medication to the clinic, making it easier for them.

However, medical billing increases costs for the provider as they have to purchase and stock the medications, which can be expensive. It also puts the responsibility on the provider to resolve any issues with the medication, such as temperature excursions or drug delivery device malfunctions.

Both pharmacy and medical billing have their advantages and disadvantages. Pharmacy billing is generally simpler and more convenient for providers, as it frees up administrative time. In contrast, medical billing can be more profitable for providers but comes with additional financial risks and time commitments. Ultimately, the choice between the two depends on the specific circumstances and preferences of the provider and patient.

Understanding prescription insurance cards

Prescription insurance cards contain important information about your prescription drug coverage. The card will usually include your name, member ID, plan number, and plan name. It may also include the RxBin (Bank Identification Number), RxPCN (Processor Control Number), ID, and RxGrp (prescription group number). These numbers are used by the pharmacy to process your prescription and submit a claim to the correct insurance company.

Some insurance companies cover prescription costs along with medical coverage, in which case, the letters "Rx" will be printed on the card. If the insurance company does not cover prescriptions, they may print the information of the prescription insurance company on the card.

It is important to carry your prescription insurance card with you at all times, as you will need to present it at the pharmacy when picking up your medications. If you forget your card, you may be able to locate your digital membership card through your insurer's smartphone app.

Prescription discount cards are different from prescription insurance cards. They can be used to obtain immediate discounts on medications, but they cannot be used together with insurance cards.

Pharmacy techs' knowledge of prescription reimbursement

Pharmacy technicians are responsible for various tasks, including processing and tracking insurance claims, preparing intravenous medications, and managing the supply chain. They work closely with licensed pharmacists to meet patient needs and must possess strong communication skills, computer literacy, and attention to detail.

An important aspect of a pharmacy technician's role is their knowledge of prescription reimbursement, which involves understanding insurance plans, billing procedures, and resolving issues that may arise during the billing process. They should be adept at handling insurance claims, prior authorizations, and communicating with insurance companies to facilitate patient access to necessary medications.

Pharmacy technicians need to be familiar with different insurance programs, their eligibility requirements, and reimbursement types. This includes understanding private and federally-funded insurance programs such as Medicare, TRICARE, and Medicaid. They should also be well-versed in handling prescription drug tiers, formularies, and co-payments, ensuring that patients are aware of their financial responsibilities.

Additionally, pharmacy technicians play a crucial role in prior authorization, which is an administrative process requiring additional documentation and clinical support for payer approval. They collaborate with prescriber offices and insurance companies to navigate coverage determinations, such as drug tiers, formularies, quantity limits, and step therapy.

To enhance their proficiency in prescription reimbursement, pharmacy technicians can pursue certifications like the Billing and Reimbursement Certificate offered by the National Pharmacy Technician Association (NPTA) or the PTCB Billing and Reimbursement Certificate. These certifications equip technicians with a comprehensive understanding of billing and reimbursement processes in a pharmacy setting, enabling them to facilitate patient access to medications.

Overall, the knowledge of prescription reimbursement among pharmacy technicians is essential for ensuring patient access to necessary medications, streamlining billing procedures, and providing valuable support to licensed pharmacists.

Pharmacy techs' restrictions on patient advice

Pharmacy technicians are not trained or licensed to advise customers about medications and their use. They are legally prohibited from counselling patients and can face serious consequences if they do so.

Technicians can, however, instruct patients according to the directions printed on the medication bottle. They should make it clear that they are referring to the manufacturer's instructions and that individual use may vary according to a doctor's advice.

Pharmacy technicians can answer simple questions, such as whether a medication needs to be taken with food. They should use their best judgement to determine whether a customer's query exceeds common pharmaceutical knowledge. If in doubt, they should refer the patient to a pharmacist.

Technicians are also able to explain the scope and extent of a patient's insurance benefits.

Frequently asked questions