Pharmacists have never been at ease with pharmacy billing requirements because of the complex procedures needed to make the bills accurate and compliant. Over the years the problem has been further compounded by the recent trends of falling reimbursements and rising DIR fees. To counter the double impact, pharmacists have now taken to providing clinical care services to patients. In the process they have added yet another problem to their plate of problems – billing in lockstep for a service that differs widely from pharmacy billing.
To start with it begins with the billing format. The billing format for clinical services provided by a pharmacist and a provider is different. Unlike medical billing, billing payers for prescriptions requires prescription numbers and NDC (National Drug Codes). Therefore, to bill for medical benefit availed by patients for their insurance plans, it’s important for pharmacists to be aware of and stay up to date with the Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS).
Added to this is the complexities of medical billing. Unless pharmacies are aware of these billing for other services can become very difficult for pharmacies. Unlike hospitals and clinics that have full-time positions to deal with billing and coding complexities —pharmacies have to bill without the support of these dedicated experts. Additionally billing for clinical care is a detailed and time taking task, and pharmacies cannot afford to spare the time needed.
An easy way out for pharmacies is to outsource pharmacy billing services to an accomplished third-party service provider. These providers have trained and experienced pharmacy billing staff to take care of all the intricacies of pharmacy and clinical bills. Besides they always stay updated with changing HIPAA rules and regulations and have information about drug codes on their finger tips, thereby taking away a big chunk of worry from your plate.
| Pharmacy billing cycle The pharmacy billing workflow across all pharmacy types in the US can be broken into the following steps: Receiving the prescription Mapping patient data Keying in data Claim transmittal Third-party payer adjudication Point-of-sale Payment processing |
The Common Problems that Outsourcing Helps to Overcome
Outsourcing helps to overcome a host of problems faced by pharmacies. However, some common pharmacy billing problems that can be solved seamlessly by a third-party provider:
A/R is Getting Older:
Aging A/R is a common challenge faced by pharmacies. In fact this is most common across all infusion pharmacies. What this means is that when the oldest accounts exceed 90 days, they get into the realm of write-offs. And when you have a greater number of them, you are staring down the barrel. And to worsen matters there is no proper means and strategy to deal with it. Therefore, when your high-dollar A/R requires focused attention, you are short of resources to implement a strategy to recover the outstanding accounts.
Lack of Experienced Billers:
Yet another challenge faced by pharmacies is attrition which is why they have to settle for less experienced billers. And the costs for this more often than not is very high. With inexperienced billers you have deal with issues like incorrect coding, improper billing calculations, incorrect modifier usage, incorrect primary payer billing etc. Some pharmacies believe they can get over this by having a sound QC team. But the QC team too is susceptible to errors because they often are made to bite more than they can chew.
The Audit Specter:
When there are too many errors you will have the auditor knocking on your door. And be it Medicare or other payers, when they come knocking, they won’t leave any stones unturned to spot the faults in your process. If established, you will have to face the consequences that can range from huge fines to cancellation of payer contracts. So, to keep the auditor at bay, it’s important to have proper control over your process. If not, you may have to carry out regular internal audits with the help of third party agencies, which again be too costly.
Updates In Healthcare Industry:
The healthcare industry is coming up with rules for pharmacists thick and fast. Staying up to date with these rules can ensure your reimbursements are always on time. However, while trying to do more with less, pharmacy billers hardly have the time to stay updated with rules. For instance, not being aware of changed drug dosage requirement can lead to issues. Besides, your software and the billing must be in sync with the latest federal rules and codes for different drugs. Your staff also require adequate training to adapt to the latest rules.
| Pharmacy Services and Their Types Clinical This type of services entails a bundled payment module. It requires handling paperwork all of which is non-clinical in nature. In this type of billing care has to be taken with the paper trial. Home Care This type of service involves delivery of injectables to patients from home. These services are covered by Medicare Prescription Drug Improvement and Modernization (MPDIM). It requires data handling that may not be integral to your core competency. Managed Care This service is similar to clinical services and are carried out from big hospitals and nursing homes that realize their reimbursement through the bundled payment model. It entails heavy non-clinical paperwork and constant report generation. Radio This is an important adjuvant therapy services and is covered by the Medicare Prescription Drug Improvement and Modernization Act (MPDIM). It requires intensive expert billing and coding assistance. |
Patient Satisfaction
There is yet another important requirement for staying up to date with rules and information – the need to know about drug allergies . Pharmacy vigilance department keep sending updated information about allergies caused by different drugs. not being aware of this update can lead to billing of these drugs and consequently denial of claims. There is yet another spin off to a failure to stay abreast and i.e. poor patient satisfaction. This may translate into loss of reputation.
Incorrect Payment Posting in Pharmacy Billing
Pharmacies often have to deal with the fall outs of incorrect posting especially when they are running short of staff. As a result it leads to incorrect A/R calculation. This again leads to loss of revenue and affects revenue inflow. Without a proper payment posting process the problems keep recurring and some of these recurrences may even lead to denials.
Your success with outsourcing largely depends on the type of provider you choose. Off course experience does matter the most. Always look for a provider who has equal expertise of both pharmacy and medical billing. This way you get the best of both worlds. But along with that you need to look for vendors who don’t nickel and dime you with variable costs, hidden fees, and more. When you ensure this you make sure you get value for the money you invest.
Who We are and What Makes Us an Expert
We are a BPO company specializing in a range of healthcare BPO services including pharmacy billing services. We have vast experience in addressing the common reimbursement challenges faced by pharmacies. We regularly train our staff thereby ensuring our clients do not have to put up with needless claim denials. We provide complete revenue cycle management solutions to ensure client satisfaction. Tell us your problem and we will tap into our experience to find the most apt solution for your needs. Talk to our experts now to learn about our expertise in transforming pharmacy billing services.
