Many times people applying for health insurance coverage exclude pertinent underwriting details during the initial application process regarding an applicant’s medical history or more specifically the utilization of certain prescription drug medications. Most often prospective applicants think it is of no real importance, however a health insurance application which disregards the proposed insured’s current or previous health status only to discover consumption of prescribed drugs is indicative of high risk and could result in a declination.
The list of medications scrutinized carefully by a health insurance underwriter is extensive but the question most applicants ask is; how on earth do they get this data in the first place? I wanted to write this article so prospective applicants can better understand and prepare themselves so they do not get rejected prematurely by an insurer but first lets take a look at the role two popular highly interoperable databases utilized during the underwriting process work known as the Medical Information Bureau and Pharmacy Benefit Management.
By now most of the public already is aware about the Medical Information Bureau a non profit organization who shares and exchanges applicant information to member insurance companies. The Medical Information Bureau does not contain detailed electronic health records in their repository collection such as EKG readings, Blood Test results, and other diagnostic test which could be of real significance and value to insurance carriers.
Instead the database contains codes which serve as warnings in the medical underwriting process and in most cases if the applicant has had group insurance for most of his or her lifetime and has not applied for individual private health insurance there is a lack of communicable information and in which case the insurance carrier will most likely request an attending physician statement commonly known as an APS or the insurer will request a paramedical examination. Even will all these protocols in place to investigate the proposed insured there is still the possibility that vital information is missing especially if the attending physician statement is missing documentation and records from an applicant prescribed medication from another practitioner of medicine such as a specialist. There are many databases used in health insurance underwriting and one being used more frequently today involves the usage of Pharmacy Benefit Management.
A Pharmacy Benefit Manager is a Third Party Administrator of prescription drug programs. They are primarily responsible for processing and paying claims for medications. They are also responsible for developing and maintain the formulary, contracting with pharmacies, and negotiating discounts or rebates with pharmaceutical manufactures. The focus on medication management promoted the deployment of a variety of interrelated systems. Generally, the medication management system encompasses four key areas: prescription, transcription, dispensing, and administration. Prescription covers the writing of patient medication orders. Transcription includes the transfer of orders to generate review and formulation activities in the pharmacy. Dispensing encompasses the preparation of the medication for delivery to the patient. Medication administration covers activities related to giving a medication to a patient. Lets look in more detail.
Prescription: Electronic prescription occurs through the use of computerized practitioner order entry (CPOE) systems. The functionality inherent in these systems varies greatly depending upon the intended user such as physicians or case management. CPOE often includes clinical decision support (CDS). CDS during medication management regularly utilizes medication databases that provide drug interaction and dose checking information during the initial phase of medication prescription.
Transcription: Transcription utilizes pharmacy systems that help pharmacist process medication orders and assist in pharmacy management. In addition, these systems often offer medication order checking through the use of pharmaceutical databases similar to those used during the prescription phase of medication management.Tags: electronic health records, health insurance underwriter, medical information bureau, member insurance companies, pharmacy benefit management