Summary: Help Process Insurance Claims and Payments
Amanda DeMarzo
Mar 16, 2021
5 minutes read
Handling insurance claims and processing insurance are important functions within the pharmacy. There are roles dedicated to dealing with insurance claims, payer policy, and prior authorization. Dr. Amanda DeMarzo, PharmD, MBA, PACS is the Associate Director, Patient Access with the National Board of Prior Authorization Specialists. She encourages enhancing patient access through education and certification. In this article from Pharmacy Times, she breaks down the opportunities for pharmacy technicians and pharmacists.
Non-traditional Pharmacy Opportunities
Pharmacy technicians and pharmacists are exposed to many types of interactions with insurance companies and their processes. This includes trying to process claims, communicate with insurance companies, or explain what a prior authorization is to a patient.
Fortunately, this is valuable experience for transitioning careers.
Managing Health Insurance Policy
There are many instances in which a pharmacy technician deals with coverage and utilization management. These are the processes and policies in place that decide what gets covered, how much of it is covered, and when the patient can get a refill of the medication. Particularly the following:
- Drug Tiers. The assignment of a drug product to a level of coverage or cost sharing.
- Formularies. The prescription drug list that consists of preferred medications.
- Quantity Limits. This is the number or quantity of a medication that is allowable in an interval of time (usually monthly).
- Prior Authorization. The administrative requirement to prove if the medication is necessary for the patient.
- Step therapy. The preferred treatments that must be tried before the insurance will cover a more expensive therapy option.
Specialized Pharmacy Knowledge
With this specialized knowledge, pharmacists and pharmacy technicians have opportunities for career development. Therefore, becoming certified can lead to roles that handle prior authorizations and billing for health systems, insurance companies, mail order and specialty pharmacies, and pharmaceutical manufacturers.
The Prior Authorization Certified Specialist program can also lead to further opportunities and career development for both pharmacy technicians and pharmacists. Additionally, other opportunities include field access specialist, financial navigators, or patient access specialists.
Successful Pharmacy Career Path
The experience one gains as a pharmacy technician can help to bridge gaps for patients and expedite what is normally a lengthy process. A certified technician will also have the advanced understanding of third-party payers, claims processing, and adjudication of claims that someone who doesn’t come from a pharmacy background wouldn’t. This would allow the technician to quickly find formulary coverage alternatives. Also, cut down on the delay of the patient receiving their treatment. The certification offers pharmacy technicians and pharmacists a chance to have both a rewarding and successful career path.
For example, Ashley Benjamin, MHA, BS, PACS, CPhT, is a field access specialist. She travels to physician offices to assist with education of payer policy.
Additionally, Eva Urey, CPhT, PACS, is a certified pharmacy billing specialist who focuses on claim authorizations for her health system.
