Archive for the ‘Medicare’ Category
Monday, April 23rd, 2012
Apart from the services mentioned in our service tab, Sun Knowledge also specializes in a number of administrative services. With our extra ordinary infrastructure and dedicated staff base, we are capable of performing any administrative service in healthcare domain. Some of them are listed are below:
- Provider Choice Letters
- Provider Notifications (Newsletters and Regulatory)
- Provider Satisfaction Surveys
- Telephonic Health Plan Inquiries
- Telephonic Provider Issues and Resolutions
- Contract updating and generation
- Health Plans
- Legal guidance
- Legislative Updates
- 1099 Productions and Disbursement
- Accounts Payable
- Bank Statements
- Capitation Reporting
- Check Cutting
- Check Register
- Check Signing
- Check Stock
- Deposits and Transfers
- Financial Accounting
- Monthly Financial Statements
- Profitability Analysis by Plan by Product Monthly
- Reconciliation of Accounts
- Risk Sharing Analysis and Management
- Ancillary Provider Credentialing
- Filing and Maintenance
- Meeting material preparation
- Provider Credentialing
- Provider Databank Costs and Site Review Costs
- Provider Reminder letters
Utilization Management Services
- Auth Fax incoming
- Auth Fax outgoing
- Coalition Reports
- Daily Census
- Denial Processing Letters and Compliance
- Health Plan audits
- Inpatient Case Management
- Meeting material Preparation
- Monthly Health Plan reports
- Out of Area Log
- Outpatient Case Management
- Quarterly Health Plan reports
- Referral Processing
- UM Annual Program
- UM Statistical Reporting
Quality Management Services
- Disease Management
- Grievance and Appeals
- Health Plan audits
- Health Plan Reporting
- P4P and HEDIS Measures
- QM Annual Program and Coordination
Customer Care Services
- Health Plan reporting
- Health Plans Calls
- Incoming Auth Inquiry Calls
- Incoming Claims Inquiry Calls
- Member Calls
- Member Surveys
- Provider Calls
- Benefit Option and Copays Loading
- Capitation to Eligibility Reconciliation
- Electronic Eligibility Loading
- Eligibility Reconciliation
- Eligibility Reporting to PCP
- Eligibility Template Maintenance
- CPT, HCPC, REV Coding Maintenance
- Customized Management Reports
- DOFR Maintenance and Verification
- EDI Access
- Encounter Data reporting
- Fee Set Maintenance
- Health Plan Options Maintenance
- ICD-9 Maintenance
- Inloading of Claims (Scanned and Electronic)
- Off site back-up of data
- PCs and Local IT Support
- Phone Lines (Outbound and Inbound Phone Lines)
- Provider data Maintenance
- Scanning of Claims
- System Support and System Redundancy
- Vendor data Maintenance
- Adjudication of Claims
- Auditing of Claims
- Health Plan Audits
- Health Plan reporting
- Mailroom (Batching/Sorting of inbound Claims)
- Pre-check run Review and Modifications
- Revenue Recovery Retro Terminations
- Revenue Recovery VE
- Third Party Payor Management
- Virtual Examiner claims scrubber
- Audit Preparation
- Audit Scheduling
- Fraud and Abuse monitoring
- HIPAA monitoring
- Implementation of new regulations
- Regulatory updates to policy and procedure manuals
Outsource any of your administrative service needs to take advantage of our cost effective structure.
Tuesday, February 1st, 2011
For ages, insurance companies and politicians have vehemently proclaimed that the US healthcare system is perhaps the best of its kind in the whole world. However, as its fatal flaws unfolded, the unfaltering faith of 42 million Americans in the entire system was badly shaken. There are scores of Americans, who are without proper health insurance. This gives vent to the fact that the American healthcare system may not be entirely invincible, infallible, as claimed by the healthcare pundits and political bigwigs. Astronomical healthcare costs, coupled with lack of access, pose a major threat to the US government. People are slowly coming to terms with this hard reality. Instead of taking the bull by its horns and addressing the problem head-on, the US government has been either shoving it under the carpet or proposing short-term, patch-work solution.
According to the comparative studies, conducted on the healthcare systems of various countries, the determinants of a good healthcare system are essentially its responsiveness and the extent to which it guarantees good health and financial protection to everyone. A sound, stable and unprejudiced healthcare system will, therefore, ensure:
i) Optimal good-health and an even distribution of the same across every population groups
ii) Even distribution of financing healthcare amongst all Americans, irrespective of class, creed, gender, race, age and color
iii) Tremendous, overall responsiveness and a fair distribution of the same in the society
The US healthcare, off late, falls short of everything that makes a sound, cost-effective, reasonably user-friendly and accessible healthcare system. Owing to the consistently rising costs of medical technology and prescription drugs, US boasts of the most expensive healthcare in the world. Moreover, the shift from not-for-profit providers to for-profit providers has triggered an abrupt rise in healthcare costs by a whopping percentage. The administrative costs at for-profit hospitals also attribute to the phenomenal healthcare spending. A large chunk of uninsured American population has also added to the woes, necessitating expensive healthcare.
US is the world’s only developed, industrialized country that does not promise universal healthcare coverage to all its citizens. Although quite a few employers take pains to insure their employees and the Government specifically offers insurance coverage to senior citizens (Medicare), the military as well as the unprivileged and disabled, a vast majority of the population still remains uninsured, wallowing in the woes, inflicted by this apparent “non-system”.
Lack of insurance coverage can pose a serious threat to a particular segment of the American population that does not have any access to the basic amenities of life, let alone a decent healthcare system. This shambolic system creates a gnawing gap in the coverage, which is hard to seal. As insurance rates go up, employers cannot help but stop their insurance benefits altogether and those who do not, are compelled to raise premiums and deductibles.
The US healthcare reform is indisputably a welcome relief, in these uncertain times. It will make healthcare accessible to millions of Americans, who have been regularly putting their health on hold because they cannot afford basic treatment or even the co-payment of a routine physical. The healthcare bill is believed to benefit more than 95% of legal American citizens. Even, those who have lost their jobs to recession and unfavorable times, will be able to make the best use of their coverage.
Giving unprecedented, uninhibited access to healthcare also beckons one pressing problem that all Americans have to brace for, whether they want to be covered or not. The dark clouds of recession have lifted from the face of America, with the nation successfully and bravely riding out tough times. However, it will be a “hard slog” for politicians to recover the money, lost during the credit crunch, in order to finance their health insurance scheme. This may lead the Government to consider increasing the tax of the US citizens in general and even, many businesses. As a result, people, who are not covered, can wind up paying more taxes than the ones, who are insured.
Wednesday, September 1st, 2010
Outlined in the Medicare Prescription Drug, Improvement and Modernization Act of 2003, the new reimbursement opportunity allows pharmacists to bill the federal government for meting out counseling sessions to certain covered patients with regards to their prescription drugs. The legislation, effected in 2006, mandates that all insurance providers, offering a Medicare Prescription Drug Plan, must render Medication Therapy Management Services to eligible candidates and compensate licensed and qualified health care professionals for conducting counseling sessions for the patients.
According to the Centers for Medicare and Medicaid Services (CMS), the fee, reimbursed by plan sponsors, must justify the time and resources that the relevant health care provider has invested in the patient, while providing Medication Therapy Management services. Many questions, in relation to the payment and fee-structure of a Medication Therapy Management( MTM ) program, still remain unasked, unsolved and thus, invite speculations.
The reimbursement rates and criteria vary with specific prescription drug-plans and hence, are unique. Although CMS does not interfere with regards to the dispensing fees that pharmacies manage to secure from plan sponsors, it requires sponsors to give a comprehensive explanation of the fee structures of their MTM programs. Only pharmacists, providing services that are validated by the relevant state’s “scope of practice”, are entitled to MTM reimbursements. Pharmacists, in order to practice, have to abide by the rules and regulations, issued by the state.
Drug plans are still trying to figure out proper ways to compensate pharmacists, but most of them follow the variants of fee-for-service model, paying fees for fixed services either directly to the pharmacist or to the organization, he/she works in behalf of. A typical reimbursement schedule covers comprehensive medication reviews, sessions with the primary health care provider, patient compliance and over-the-counter medication consultations, refusal from the end of the prescriber and patient’s education as well as thorough monitoring.
Counseling sessions can be arranged on the request of any of the patient, his caregiver, plan sponsor, pharmacist and/or prescriber. Any person, covered by Medicare, can avail of these sessions, as and when required. Even if a patient struggles with his expensive prescription drugs, if he has not signed up for the Medicare Part D benefit, MTM will not apply to him. Pharmacists can claim reimbursements for their designated services, only when they sign an agreement with the relevant drug plan or Medicare Advantage Plan in their area.
Lately, the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel has recognized three billing codes- Code 0115T, Code 0116T and Code +0117T- for pharmacists in order to bill third-party payers, while conducting Medication Therapy Management services face-to-face between a pharmacist and a patient. PSTAC, primarily founded to enhance the overall coding infrastructure, has created a Place of Service (POS Code 01) code, in addition to other POS codes (Code 11, “Office,” or 99, “Other Place of Service”), efficiently harmonizing pharmacists and their professional services into the traditional medical services billing model. Pharmacists can easily avail of this code in order to bill for services in a pharmacy setting.
Monday, July 26th, 2010
The Medicare Modernization Act (MMA), passed in the year 2003, mandates the provision of MTM services to elderly beneficiaries as an integral part of the Medicare Advantage and Prescription Drug Plan, offering Medicare Part D benefits. According to the act, MTM is an extension of the drug therapy management program that can be provided by a physician to optimize the use of medications and fend off adverse drug events.
An MTM, in a community pharmacy set-up, quintessentially has five facets and is offered free of cost:
• Medication Therapy Review
• Personal Medication Record
• Medication Action Plan
• Intervention and Referral
• Documentation and Follow-up
Medication Therapy Management program essentially involves face-to-face, interactive, inclusive sessions with a seasoned clinical pharmacist, who thoroughly reviews the medications, taken by the patient. The pharmacist works in close partnership with the patient, his doctor(s) and family, understanding his medication complications and then, assisting him with safe and effective medications, so that he can make the best out of the same.
A clinical pharmacist enables his patient to clearly understand his medications, answering all his queries efficiently. He also checks a patient’s medicines for adverse drug reactions that can be detrimental to his health and doles out valuable advices on how to take medicines that can successfully reduce the risks of side effects. A pharmacist also replaces branded drugs with their cost-effective, generic versions, ensuring that the patient stringently adheres to his simplified drug formulary. The patient, in question, always remains under the strict supervision of his pharmacist, who unswervingly and consistently monitors his medical conditions and relevant medications, enabling him to reap maximum benefits from a typical MTM program.
Medicare Part D participants, who either suffer from two or more chronic diseases or consume multiple Part D covered drugs or likely to splurge $4000 or more on medications, once a year, can opt for Medication Therapy Management Program. However, from 2010 onwards, the CMS will mete out new guidelines, which will make the program more accessible to the mass. According to the new mandates of MMA, Medicare Part D Prescription Drug Plan sponsors, offering services pertaining to MTM, must fulfill the conditions below:
i) Optimize targeted therapeutic outcomes by improving the use of medication
ii) Minimize risks, leading to adverse drug events
iii) Partnership with licensed health professionals, including practicing pharmacists and physicians
iv) Specification of the resources, including the fees of pharmacists as well as health professionals and time taken to execute a program, if external staff are used
v) Capable of distinguishing services in ambulatory settings from the ones in institutional set-ups
vi) Run in harmony with any health care management plan established for a targeted individual under a chronic care improvement program (CCIP)
Members, participating in both standalone 2010 Medicare Part D Pharmacy (PDP) benefits plans and comprehensive Medicare Advantage medical benefits plans, can avail of MTM services. Ideally, appropriate MTM services should be rendered on an ad-hoc basis, as soon as the complications of the patient are spotted. Medicare Part D plans prompt the communication of MTM outcomes to the CMS.
Thursday, April 15th, 2010
There aren’t any fixed educational or experiential criteria for pharmacists, or other health professionals, who are licensed to dish out Medication Therapy Management services. In most cases, a doctor of pharmacy (Pharm.D) is an eligible provider of Medication Therapy Management(MTM) services. The same rule applies to a fresh graduate. If he lacks sufficient professional experience to do his job effectively and efficiently, an extra training and education in geriatrics will help seal the gap.
If a pharmacist has a certification in a certain area, he is, inevitably, more adept in providing core MTM services in those specialty areas. Pharmacists, who are science graduates with years of professional experience under their belts, are also at par with the ones, who have certifications.
All drug-plan sponsors must employ people with versatile and complementary skills, experience and knowledge. Every plan should have a minimum educational and experiential standard which all MTM service-providers, including all community-based pharmacists and other health professionals, must meet, before they are recruited. Plans should also incentivize their work-force, encouraging them to work better and harder. The entry-level Pharm D degree and specialty certification have, indisputably, added a whole new dimension to this profession. Health-professionals are contemplating other forms of recognition, customized and tailored to the needs of MTM programs.
Thursday, March 25th, 2010
Medication Therapy Management services can be extended to prospective patients, who are in dire need of help. They can be spotted by a pharmacist, a physician or any other licensed healthcare professional, the health plan, when medication-related problems surface.
At times, the patients themselves seek medical attention, as soon as they become susceptible to medication-related problems, especially, in the wake of any healthcare setting changes or when they switch physicians. The problems may also appear, if the payer status of a beneficiary changes. These transitions of care pave the way for medication therapy changes, triggered by changes in the patient’s needs or location or resources or his health status or condition, or formulary requirements. Pharmacist-oriented MTM services must primarily dwell on reconciliation of the patient’s medications, thus providing appropriate medication management, during transitions of care. For ambulatory patients, Medication Therapy Management services are usually offered by appointments but, in exceptional circumstances, may also be provided on a walk-in basis.
Medication Therapy Management services, according to the mandates of the Health Insurance Portability and Accountability Act, must be delivered by pharmacists in a private or semiprivate area. In other patient care settings- acute care, home care and managed care, these services are dished out in a markedly different environment because of variability in structure and facilities design.
Thursday, March 11th, 2010
At times in the medication therapy management process a more detailed, in depth and comprehensive review of a patient’s medication is done which in technical terms is called comprehensive medication review.
A complete comprehensive medication review in medication therapy management assesses the following -
The necessity of the medicine
The effectiveness of the medicine
Whether taken medicines have any side effects ?
Could the medicine dose be reduced, simplified or scheduled in a better way ?
Whether medicine being taken can be more cost effective?
Whether the patient understands what the medicine is for and how to take them for most benefit
Friday, March 5th, 2010
For medication therapy management practice you need to have the following skill set, expertise and experience -
Sound Knowledge of Clinical Services
Good Communication Skills
Prior patient care knowledge
Strong relationships and reputation with area physicians
Tuesday, February 23rd, 2010
Medication Therapy Management is primarily concerned with the improvement of a patient’s healthcare outcome through reduction of prescription drugs. This calls for proper and suitable intervention through drugs/prescriptions or medicines as the case may be.
The basic objectives of a medication therapy management program are as follows –
- Reporting as per CMS guidelines
- Reducing drug cost and improving formulary adherence through therapeutic interchange program
- Handling of redetermination appeals as per CMS requirements under the guidance of a board certified physician and medicare specialist.
- Coverage determination according to benefits plan design and formularies.