Basics of Managed Care Claims Processing: From Claims Payment to Outcomes Management

Abstract

OBJECTIVE: Describe the evolution of prescription claims processing from claims payment systems designed in the 1970s to interactive point-of-service (POS) systems that enable pharmacists to conduct prospective drug-use review; and discuss current programs that link prescription databases with medical, hospital, laboratory, and other health care records; and explore the benefits and limitations of electronic point-of-service systems for providers, payers, and patients. DATA SOURCES: Not applicable. DATA EXTRACTION: Not applicable. DATA SYNTHESIS: Claims-processing systems have developed quickly from the completion of manual forms in the 1970s, to standardization of forms using the National Drug Code and the National Pharmacy Identification Code; to the real-time point-of-service (POS) systems of the 1990s that provide management functions. POS systems benefit the pharmacy, patient, and pharmacy benefit management company. The capability of performing prospective drug-use review is one of the most important advantages of POS systems. On-line systems also form the basis for measuring the outcomes produced by a particular pharmacy and for conducting outcomes research studies. CONCLUSION: Claims databases will be used more for research, patient case management, and evaluating the performance of pharmacists and other health care providers.