A Drug Trend report published in 2009 had predicted continued price increase among traditional branded and biotech drugs that lack generic competition. Now, further, CMS has reduced its Average Sales price (ASP) margin from 6 percent to 4 percent for non-pass-thorough. This has affected pharmacy reimbursement. However, there are certain other aspects of Pharmacy Billing that can affect reimbursement and thereby the Revenue Cycle Management (RCM) process if not well implemented.
1. Data Workflow:
Recognizing how the revenue cycle works in pharmacy is very essential. Procurement to Inventory, billing and reimbursement involves purchase of medications, their storage, and method of dispensing, how they are administered, way they are coded & billed, and finally reimbursed. If the drug is covered as a pharmacy benefit, or the payer needs that to be obtained via a specialty pharmacy as identified through patient-specific benefit verification, then here both the provider and the pharmacy are part of the reimbursement process. The physician writes a prescription and orders the drug. This is followed by the pharmacy that fills the order and issues the drug to the physician, CMHC, or hospital outpatient department. Here the pharmacy bills the insurance company for the drug. If any information is entered incorrectly into the pharmacy system in the initial phase of the cycle, errors can prove to be costly, impacting aspects of clinical and revenue cycle.
2. Procurement:
During this phase information is converted from purchased quantities and pricing to storage units of measure (UOM) and inventory costs. Manually entering the data is followed in most cases. UOM conversions, when data is uploaded from the wholesale distributor to the pharmacy system, are also checked and verified manually. Here too mistakes can lead to breakdown in the revenue cycle management (RCM) process.
3. The Charge master:
Critical & substantial revenue leakage can occur when separately reimbursable medications are either missing from or miscoded in the charge master. Conversion of pharmaceutical quantities is a must from purchased amounts to patient-administered amounts, and only then made billable. There is often a difference between dosage amounts required for patient use as from that purchased. Besides inventory, the clinician and pharmacist should convert dosage, strength, and delivery mechanism for each drug. Drug data must be correctly converted from the quantities residing in clinical systems into the payer-billable quantities appropriate for the financial system or charge master. The UOMs must be reconciled to avoid any under- or over-payments. More than often, missing or incorrect data in the charge master can result in negative financial consequences – denied claims, partial reimbursement, and compliance risks.
4. Linkages between Purchases & Billing:
Most hospitals have separate processes to order drugs, administer them, and process reimbursement. Without linkage between pharmacy expenditures for medications (i.e., spend data) and the charge master, ensuring proper charge capture and optimal reimbursement is a challenge. Besides hospitals should have automated tools to identify charge capture errors precisely, so as to pinpoint when and where their occurrence to decreasing revenue loss.
The child seems to have an infective endocarditis probably because of the skinned knee which could have acted as a route for transmission into the body and reaching the heart and causing infection leading to increased in body temperature with chills(typical signs), pounding or rapid heart rate. This also exhibits an abnormal heart murmur .It can found in children if they have some skin injury.
Treatment:
-Antipyretics to reduce temperature
-Antibiotics to treat infection
-Skin hygiene to prevent entry of bacteria via open end
The nurse suspects that an older adult patient has features of basal cell carcinoma appearing in form of a small dome-shaped lesion with a pearly surface on the face.
What is Basal cell carcinoma?
The most prevalent type of skin cancer that is not melanoma is basal cell carcinoma (BCC).
It is a tumour that causes localized damage and has a variety of clinical and histological characteristics.
When viewed at low power magnification, a basaloid epithelial tumour emerging from the epidermis is the primary characteristic of basal cell carcinoma.
Normally, the palisade-like basaloid epithelium forms a fissure from the surrounding tumour stroma.
The nuclei grow congested in the centre, with scattered mitotic figures and visible necrotic bodies.
The presence of a mucinous stroma serves as a helpful distinguishing factor from other basaloid cutaneous tumours. Additionally, some tumours may exhibit foci of regression, which are regions of eosinophilic stroma devoid of basaloid nests.
Hence, the answer is a small dome-shaped lesion with a pearly surface on the face.
The anti-atherogenic effect of HDL occurs, above all, because of its properties to carry lipids, mainly cholesterol esters from peripheral tissues to the liver, which is known as reverse cholesterol transport(RCT). However, other protective actions of HDL, in addition to RCT, have been described in several experimental models and epidemiological studies. These actions include antioxidant protection, mediation of cholesterol efflux, inhibition of the expression of cell adhesion, leukocyte activation, regulation of blood coagulation and platelet activity.
