1.
(a) Most self-management education focuses on
the lower three levels of Bloom's Taxonomy
of Educational Objectives: 1) knowledge, 2) understanding,
and 3) application. If patients are unable to
answer questions, it may be that the questions
being asked are at a level that is too high for
them. A simpler question at a lower level will
usually help. For example, if patients seemed
unable to discuss how to prevent hypoglycemia,
then a question at the understanding (application)
level would be appropriate. For example, What
have you learned about low blood sugar reactions?
Conversely, if patients can answer questions too
easily, then more complex questions at a higher
level of the taxonomy are appropriate.
2.
(d) All. Each protocol developed, pursuant to
the collaborative drug therapy management agreement,
shall contain detailed direction concerning the
actions that the pharmacist may perform for that
patient. The protocol shall include, but need
not be limited to, (1) the specific drug or drugs
to be managed by the pharmacist, (2) the terms
and conditions under which drug therapy may be
implemented, modified or discontinued, (3) the
conditions and events upon which the pharmacist
is required to notify the physician, and (4) the
laboratory tests that may be ordered. All activities
performed by the pharmacist in conjunction with
the protocol shall be documented in the patient's
medical record. The pharmacist shall report at
least every thirty days to the physician regarding
the patient's drug therapy management.
3.
(b) The partial supply of Schedule II controlled
drugs is only permitted after 72 hours if the
patient resides in an LTCF or the patient is diagnosed
as terminally ill.
(d) The principal components of a Pharmacy Benefit
Management (PBM) program are:
1.
A legally enforceable benefit design contract
that outlines covered and excluded benefits.
2. A defined physician provider network under
contract with the health plan.
3. A defined pharmacy provider network under contract
with the health plan or PBM.
4. A community pharmacy network with point-of-sale
(POS) computer adjudication system.
5. A drug formulary.
6. A mandatory generic substitution program.
7. Pharmaceutical manufacturer discounts or rebates.
8. A patient prescription co-payment.
9. Retrospective drug utilization review (DUR).
10. Drug formulary conversion.
11. Compliance improvement.
12. Disease management program.
4.
(d) The principal components of a Pharmacy Benefit Management (PBM) program are:
1. A legally enforceable benefit design contract that outlines covered and excluded benefits.
2. A defined physician provider network under contract with the health plan.
3. A defined pharmacy provider network under contract with the health plan or PBM.
4. A community pharmacy network with point-of-sale (POS) computer adjudication system.
5. A drug formulary.
6. A mandatory generic substitution program.
7. Pharmaceutical manufacturer discounts or rebates.
8. A patient prescription co-payment.
9. Retrospective drug utilization review (DUR).
10. Drug formulary conversion.
11. Compliance improvement.
12. Disease management program.
5.(d)
All. Health Plan Employer Data and Information
Set (HEDIS) is a set of standardized measures
of health plan performance. HEDIS allows comparisons
between plans on quality, access and patient satisfaction
membership and utilization financial information
and health plan management. HEDIS was developed
by employers, HMOs, and the National Committee
for Quality Assurance (NCQA). There are eight
major categories included in HEDIS:.1.
Effectiveness of care.
2. Access and availability of care.
3. Satisfaction with experience of care.
4. Health plan stability.
5. Use of services.
6. Cost of care.
7. Informed health services.
8. Health plan descriptive data.
6.
(b) General member satisfaction can be measured
by qualitative and quantitative assessment of
telephone inquiries on help lines. Help lines
assist the plan member to resolve inquiries related
to pharmacy benefits. Automatic call distributor
(ACD) measures the help line performance for PBM.
The following industry standards are verified
or measured:.
1.
Calls received.
2. Calls answered.
3. Calls abandoned.
4. Abandoned rate.
5. Percent of calls answered within 30 seconds.
6. Average speed of answer.
7. Average talk time.
7.
(d) Atomoxetine (Strattera) is the first and only
non-stimulant medication approved by the US Food
and Drug Administration (FDA) for the treatment
of attention-deficit/hyperactivity disorder (ADHD)
in children, adolescents, and adults. It is a
norepinephrine reuptake inhibitor, a class of
ADHD treatment that works differently from the
other ADHD medications available. All other choices
are controlled substances that can be diverted
or abused.
8.
(a) Reactively. States use different approaches
to analyzing the prescription information they
receive. A few states routinely analyze prescription
data collected by the PDMPs to identify individuals,
physicians, or pharmacies that have unusual use,
prescribing, or dispensing patterns that may suggest
potential drug diversion, abuse, or doctor shopping.
States refer to this as a proactive approach to
identifying drug diversion. Trend analyses are
shared with appropriate entities, such as law
enforcement, practitioners, and regulatory and
licensing boards.
In contrast, most state PDMPs generally use the
prescription data to respond to requests for information.
These requests may come from physicians or from
law enforcement or state officials based on leads
about potential instances of diversion. According
to state program officials, most PDMPs operate
in the latter fashion, which is called reactively,
because of the increased amount of resources required
to operate a proactive system.
9.
(b) Medigap usually covers the Part A coinsurance
and for the cost of 365 extra days of hospital
care during a patient's lifetime after Medicare
coverage ends. It also covers the Part B coinsurance
(generally 20% of the Medicare-approved payment
amount) and foreign travel emergency. In addition
to these, some plans may cover limited prescription
drug benefits and offer preventive care. .Medigap
policy does not cover:
.1.
Long-term care.
2. Vision or dental care.
3. Hearing aids.
4. Private-duty nursing.
5. Unlimited prescription drugs.
10.
a
Current DUR procedures in most healthcare plans
focus on product-centered utilization trends.
For example, at the time of analyzing a DUR study
most of the attention is given to drug products
in terms of dollar costs and total unit dispensing
rate. This sometimes may result in unwarranted
physician inquiries and intervention that are
not clinically significant. For example, if a
patient is taking a proton pump inhibitor for
several months, the computer will mark the patient
profile to be reviewed for DUR under the category
of exceeds appropriate duration of use. The
DUR performer in this type of study does not look
in depth for the past patient history of severe
erosive esophagitis or gastric surgery.
In
most cases, the drug has been used appropriately,
however the person performing the DUR has been
forced into product-centered DUR without considering
the patient past history or clinical status. Switching
to patient-centered DUR study provides more accurate
clinical status of the patient and helps in controlling
healthcare cost as well as healthcare related
services more efficiently. In this type of study,
importance is primarily given to inappropriate
utilization of medications and screening of targeted
patient-population. For example, patients who
are elderly with prior history of bone fractures
and falls may be screened for drugs that may potentially
cause additional falls and fractures or for drugs
that may adversely affect bone mass index. This
may include excessive or inappropriate use of
sedatives or benzodiazepines, which may cause
additional falls.
11.
(a) The following coding systems, ICD-9-CM, CPT-4
, and HCPCS, were adopted as standard code sets
under the Health Insurance Portability and Accountability
Act (HIPAA). Effective October 16, 2003, all covered
entities are required to use these national coding
systems.
.1.
ICD-9-CM is the official system of assigning codes
to diagnoses and hospital procedures in the United
States. Volumes 1 and 2 comprise diagnostic codes,
and Volume 3 lists certain hospital procedure
codes. ICD-9-CM is maintained jointly by the National
Centers for Health Statistics and the Centers
for Medicare and Medicaid Services as part of
the ICD-9-CM Maintenance Committee. ICD-9-CM is
modified annually to accommodate new terminology
and procedures, and to update outdated nomenclature.
ICD-9-CM will eventually be replaced by ICD-10-CM
(diagnostic codes) and ICD-10-PCS (hospital procedure
codes).
2. CPT is a systematic coding system for
reporting medical services and procedures performed
by physicians. CPT is maintained by the American
Medical Association and is modified every year.
Revisions are usually effective for dates of service
on or after January 1 of each year. CPT also represents
Level 1 of the Healthcare Common Procedure Coding
System.
3. The Healthcare Common Procedure Coding System
(pronounced Thick-picks) was originally
created for use under the Medicare program. Today,
HCPCS is used by virtually every payer in the
United States.
12.
(d) All. Medical providers who bill Medicare,
Medicaid, and other Government programs use a
standardized system of numerical codes for patient
services. In this way, insurers and the Government
do not have to work out what services were provided
from numerous records or from thousands of different
types of coding or billing systems. Misuse of
these standardized codes to obtain more money
than is allowed by law is commonly termed "UPCODING"
or "UPCHARGING."
Each Medicare billing code is tied to a particular
group of services and will eventually result in
a reimbursement to the physician or other provider
(hospital, psychologist, chiropractor, etc.) based
upon the code entered by the provider. Providers
have financial incentives to "upcode"
or increase the bill by exaggerating or even falsely
representing what medical conditions were present
and what services were provided.
For example, when a 2-minute visit for diagnosis
and treatment of an upper respiratory condition
(i.e. a cold without complications) is "upcharged"
from a very low reimbursement rate code by intentionally
using codes for a more serious ailment. Thus,
the "URI" or "upper respiratory
infection" diagnosis is altered to indicate
that the patient was suffering from a more severe
bronchitis and sinus infection, with some breathing
impairment requiring nebulizer treatment, and
the patient required a full 1-hour office visit.
In either case, whether the additional services
billed were not even provided or if provided but
not medically needed, a fraudulent "upcharge"
occurs.
Churning occurs when a physician provides a service
to a patient more frequently than is necessary
for the purpose of billing for more services.
For example, a psychiatrist may require more sessions
with the patient than are recommended for the
condition.
Unbundling or fragmentation occurs when a physician
bills separately for services that are normally
reported as one service. Medicare and Medicaid
often have special reimbursement rates for a group
of procedures commonly done together, such as
typical blood test panels by clinical laboratories.
Some health care providers seeking to increase
profits will "unbundle" the tests and
bill separately for each component of the group,
which totals more than the special reimbursement
rates.
.
13.
(d) A Schedule II controlled drug cannot be filled
in partial amounts unless the pharmacist is out
of stock of the drug. A pharmacist may dispense
partial amounts of a drug if requested by the
patient, but cannot fill the remaining without
a new prescription. In the case of when a pharmacist
is out of stock of a drug and fills a partial
supply of the drug, the remaining must be filled
within 72 hours of initial filling.