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 information that the nurse should include in the teaching is: D. The risk for developing DKA may be increased with the use of an insulin pump
Diabetes mellitus occur when a patient body does not produce insulin that is needed by the body leading to increase in the patient blood sugar level.
Insulin pump is a pump which are use when treating diabetes patients as it help to administer Insulin into the patient body when performing insulin therapy.
DKA which fully meaning is Diabetic ketoacidosis occur when a patient body does not have enough insulin leading to what is called ketones.
The risk for developing Diabetic ketoacidosis can be increased when a patient make use of insulin pump due to the following:
•When the pump fails to function normally due to low battery.
•When their is no longer insulin in the pump.
Inconclusion the information that the nurse should include in the teaching is: D. The risk for developing DKA may be increased with the use of an insulin pump.
When administering adenosine, the nurse must inject it through the IV push route.
Explanation:
Adenosine belongs to the drug class of antidysrhythmics and hence proper care and monitoring should be taken to avoid any adverse or side effects while or after administering the dose. Adenosine should be injected only via the IV route. The injection should be made close to an IV site, so as to flush each time with NS. The patient’s heart conditions should be monitored continuously on an ECG monitor and blood pressure machine. The dosage levels should match with the age appropriately. Adverse reactions of adenosine may include transient arrhythmias, bronchospasms, dyspnea etc.
Evidence based practice (EBP) involves the decision making that integrates the best available research with clinical expertise and an understanding of patient characteristics.
EBP in simple terms involves the application of the scientific theories and findings into real practice on the patients. In EBP, the choices and preferences of the concerned patients are given utmost priority.
This means that the usage of the old and traditional practices may be discarded. The benefit of applying this phenomenon is that it involves personally designing the care-chart of each patient according to their symptoms, therefore, providing the required treatments and avoiding unnecessary medications and treatments.
