Copy of `Workers Compensation - Health insurance terms`

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Workers Compensation - Health insurance terms Category: Health and Medicine Date & country: 27/07/2014, USA Words: 82

I-STOP
- The New York attorney general (Eric T. Schneiderman) is proposing a real-time, online prescription drug-monitoring program that would require both doctors and pharmacists to instantly report the prescription and dispensing of controlled substances. They

WP
suggested wholesale price

WAC
wholesale acquisition costs

utilization
the number of scripts and the number and type of drugs dispensed; a contributor to cost, as is price. Cost=Price x Utilization. The average number of prescriptions received by an injured worker per year.

utilization trend
the annual rate of increase in pharmacy spend due specifically to an increase in the number or change in type of medications dispensed. Factors affecting changes in utilization include new brand medications, new generic launches, clinical management, age of claim, number of injured workers using medications, and number of medications per injured worker.

UCR, U&C (usual and customary)
usual and customary charge is the prevailing cost of a medical service in a given geographic area.

trend
the annual inflation percentage rate from the year prior to the immediate past year. The trend rate for 2009 is calculated by dividing the dollar amount of the increase by the total spend in the prior year.

trend basis
the metric on which the reported inflation rate is based. Except where otherwise defined, refers to the year prior to the year being discussed.

TIC
(Texas Insurance Council)

TPB
third party biller

transaction
a mechanism for a pharmacy to request approval from a health plan to authorize certain healthcare products and services, as required by the patients health plan contract. The health plan responds to the pharmacy whether the product or service is approved. The exchange of information between two parties to carry out financial or administrative activities related to health care.

therapy class
The American Hospital Formulary Service (AHFS) provides a therapeutic drug classification system that allows for the grouping of drugs by similar pharmacologic, therapeutic and/or chemical characteristics. There are many classifications available, but the AHFS system has been in existence since 1959 and includes 30 primary classifications, 183 secondary classifications, 252 tertiary classifications, and 88 quaternary classifications.

therapeutic substitution
substituting for a generic or similar medication, one that has the same pharmacological effect.

single-source brand drug
a brand drug that has no generic equivalent. There are two types of non-preferred brand drugs

step therapy
an approach to prescription drug management wherein the claimant is prescribed lower potency or alternative medications initially, succeeded by more potent medications or scheduled drugs only after the initial medications have been found to be inadequate to address the claimant's condition. Intended to control the costs and risks posed by prescription drugs.

savings
the difference between the amount paid below the fee schedule and the fee schedule, calculated either as a dollar amount or a percentage below fee schedule. In those states without a fee schedule, the basis is usual and customary.

REMS
Risk Evaluation & Mitigation Strategy. The Food and Drug Administration Amendments Act of 2007 gave FDA the authority to require a Risk Evaluation and Mitigation Strategy (REMS) from manufacturers to ensure that the benefits of a drug or biological product outweigh its risks. Notifying the sponsors of long-acting and extended-release (LA/ER) opioid drugs that they were required to submit a risk evaluation and mitigation strategy (REMS), the FDA has been working with the sponsors that market these products on the required REMS. The central component of the Opioid REMS is an education program for prescribers (e.g., physicians, nurse practitioners, physician assistants) so that LA/ER opioid drugs can be prescribed and used safely. FDA expects the prescriber training to be conducted by accredited, independent continuing education (CE) providers, without cost to the healthcare professionals, under unrestricted grants to accredited CE providers funded by the sponsors.

rejection rate
the percentage of scripts that are denied by the payer or PBM. The rejection rate is calculated by dividing the number of denied scripts by total number of scripts submitted. A timeframe should always be provided and noted to clearly identify the timeframe wherein a submitted script that is eventually filled does not affect the calculation.

prior authorization
the process of obtaining prior approval from a private or public third-party prescription insurer as to the appropriateness and coverage of a service or medication.

per member per month (cost)
the plan's cost of drugs per claimant per month, or per member in the non-workers' comp market.

pharmacy spend
drug costs in workers' comp.

PHI
Personal Health Information

price
the price per script; a contributor to cost. Cost=Price x Utilization. the average cost per prescription as a weighted average of all prescriptions.

price trend
the annual rate of increase in pharmacy spend due specifically to price; factors affecting average price include the impact of average wholesale price (AWP), new brand medications, new generic launches, and Pharmacy Benefit Management contracting.

PCMA
Pharmaceutical Care Management Association

PBM refill rate
the percentage of initial scripts that are followed by additional scripts for the same claimant and condition.

open vs. closed formulary
formularies can be either

pay without prejudice
a regulation or statute that states payment of a medical bill for a specific procedure or procedures does not imply or require the payer to accept responsibility for that diagnosis.

PBM (pharmacy benefit manager)
a third-party administrator of prescription drug programs; primarily responsible for processing and paying prescription drug claims. Also responsible for clinical pharmacy management, developing and maintaining the formulary, contracting and maintaining relationships with pharmacies and negotiating discounts and rebates with drug manufacturers.

OMFS
Official Medical Fee Schedule

off label
practice of prescribing pharmaceuticals for an indication not approved by the FDA. The FDA approves the use of drugs for certain specific conditions. Prescribing a drug for any other use is called off-label.

normalized
RxNorm provides normalized names for clinical drugs and links its names to many of the drug vocabularies commonly used in pharmacy management and drug interaction software, including those of First Databank, Micromedex, MediSpan, Gold Standard Alchemy, and Multum. By providing links between these vocabularies, RxNorm can mediate messages between systems not using the same software and vocabulary.

ODG
Official Disability Guidelines produced by the Work Loss Data Institute

Ingredient
a substance that forms part of a mixture. In the pharmaceutical industry, an active ingredient is that part of a formulation that yields the effect required by the customer.

NACDS
National Association of Chain Drug Stores

NCCI
National Council on Compensation Insurance

NCPDP
National Council for Prescription Drug Programs

NDC
national drug codes

network penetration
the percentage of billed prescriptions (electronic and paper claims) which were filled without TPB (third-party billing) involvement at participating pharmacies.

IAIABC
International Association of Industrial Accident Boards and Commission

IBNR (incurred but not reported )
those claims that have occurred before the valuation date but have not yet been reported to the insurer. Accidents that happened, but the injured worker didn

in network
services or medications provided to claimants by providers and/or suppliers that have agreed to perform certain services, usually at a discounted rate, in return for participation in a network that directs patients to their practice/facility.

home delivery
- the delivery of a patient's prescriptions to their home address via mail.

generic efficiency
estimated by calculating the percentage of the total number of scripts that could be filled with generics that was actually filled with generics.

generic fill rate
percentage of the total number of scripts that are filled with generics.

generic substitution
the process wherein a script that was written to be filled with a brand is filled with an equivalent generic.

FUL
Federal Upper Limit for generic drug cost containment in Medicaid.

GDR (generic dispense rate)
percentage of scripts dispensed that are generic.

GEAP
Generic Equivalent Average Pricing

generic drug
a drug produced and distributed without patent protection. A drug product that is no longer covered by patent protection and thus may be produced and/or distributed by many firms.

EBM
evidence-based medicine

EOB
evidence of billing

first fill rate
a calculated percentage wherein the number of initial scripts captured within the network and processed by the PBM is divided by the total number of initial scripts. It can be difficult to determine the denominator, and if the denominator cannot be established with a high degree of confidence, this should be noted.

formulary
schedules of prescription drugs approved for use for specific conditions; used to manage the types of drugs dispensed. A prescription drug plan

DUR
retrospective,concurrent, prospective: retrospective drug utilization review is looking back at an older claim; concurrent is during the life of the claim, and prospective is before the script is filled. Concurrent care exists where more than one physician renders services more extensive than consultative services during a period of time. A retrospective review is a post-treatment assessment of services on a case-by-case or aggregate basis after the services have been performed.

EAC
estimated acquisition cost

denial
refusal to authorize payment for a prescription.

DP
direct price

Drug Utilization Review (DUR)
formal program for assessing drug prescription against some standard. May consider clinical appropriateness, cost effectiveness and, in some cases, outcomes. Review is usually retrospective, but some analysis may be done before drugs are dispensed (as in computer systems which advise physicians when prescriptions are entered.)

duplicate
script which is identical in NDC code, patient, number of doses, and potency.

cost per script
the average cost per prescription dispensed and reimbursed, normalized to a thirty (30) day supply.

CWCI
California Workers' Compensation Institute

DAW
dispense as written (refers to Rx)

days of therapy
duration of treatment covered by a specific dispensed prescription.

day's supply
equivalent to days of therapy.

cost per lost time claimant
the total drug spend per reported period (month, year) divided by the midpoint of the number of lost time claims open during that period.

cost
total drug expenses for a payer. Cost=Price x Utilization

claimant
the individual person who files a workers' compensation claim.

clinically significant drug error
any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures and systems including: prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.

chronic
chronic diseases can be defined in different ways. One definition classifies a chronic disease as a condition lasting at least 3 months. Another definition defines chronic disease as a condition that can be controlled but not cured. Either way, a chronic disease requires a commitment to continue therapy for as long as needed, whether three months or for a lifetime.

claim
in group health a medical bill is called a claim; in comp, a claim is an injury event and refers to the whole life of the treatment. For workers' compensation PBM reporting purposes, a claim is the injury event and not the script.

AWP
average wholesale price

BBAWP
blue book average wholesale price

cash price
the actual cash price for that drug at that pharmacy on that day. Usually provided by the pharmacy in the electronic transmission to the PBM/payer.

avoided script
prescriptions transmitted to the PBM or payer that were not authorized or dispensed. (This requires reporting organizations to determine if scripts that were initially rejected were subsequently filled. ) If a script was not filled within thirty (30) days of the initial request, it qualifies as an Avoided Script.

approval rate
the percentage of requests for prior authorization that are authorized by the payer (or the PBM or other entity acting on behalf of the payer). In most cases there will be a 1:1 relationship between scripts and approvals; if there is not due to more than one script being authorized at one time, this should be noted.

any willing provider
In health care, a law requiring an insurer or a managed care organization to allow policyholders to receive treatment from any provider willing to accept the fee the insurer offers, even if he/she is not in the insurer's network of approved providers. About half of U.S. states have any willing provider statutes.

AIA
alternative benchmark price

AAC
Average Acquisition Cost

ABP
(American Insurance Association)

acute
plan's benefit structures are calculated to treat episodically for acute care rather than for chronic care.

age of claim
the length of time a claim is open, beginning with the date of injury or illness, continuing until the current date or the date the claim is closed by the payer, whichever is shorter.