How to Improve Pharmacy Billing Reimbursement in 9 Simple Steps

Pharmacy Times said it best: “Medical billing is now part of the job description” for pharmacists and pharmacy technicians.

There is a mutual benefit to pharmacies offering care services which can help both patients and pharmacies by more affordably improving patient outcomes and increasing pharmacy revenue.

With the United States making up over 40% of total global health spending, citizens benefit from opportunities to decrease their cost of care while pharmacies see increased revenue.

However, these revenue-driving pharmacy benefits are only applicable if clinical services are successfully reimbursed. Pharmacy medical billing can be challenging - and NCDS Medical Billing is here to simplify that process.

Factors Preventing Pharmacy Billing Reimbursement Success

Pharmacy medical care provides solutions and addresses needs for both patients and pharmacies themselves. With 90% of Americans living within a 5 mile radius of a pharmacy, offering patient care services helps Americans keep healthcare costs down while increasing pharmacy revenue.

PA Pharmacists Network infographic about pharmacy health care access

Ensure that your pharmacy earns the revenue you deserve by understanding what factors could prevent your pharmacy billing success.

Lack of Understanding of Pharmacy Medical Billing Process

With the shift to providing care in the pharmaceutical industry, pharmacies have had an increasing level of responsibilities, and with this, an expensive task that can get lost in the shuffle is medical billing.

The cost of a lack of understanding of pharmacy medical billing can be very high. Inexperienced billers can lead to denied claims, unpaid claims, and improper billing calculations

Understanding pharmacy medical billing is now vital to a healthy revenue cycle. Pharmacies should put effort and thought into how they’re billing to better serve the customer - and get better return on investment.

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Catalyst Pharmacy Podcast shares why pharmacy medical billing is more important now than ever.

Constant Updates to Insurance Reimbursement Schedules

With insurance reimbursement schedules regularly changing, pharmacies struggle to understand when they will be paid for the care that they’ve already provided.

The uncertainty and adjustments around when insurance will reimburse them for care creates delays in cash flow for pharmacies and impacts revenue cycle management. On top of all the other tasks a pharmacy team handles on a day-to-day basis, managing insurance reimbursement schedules presents an additional challenge.

Limited Resources and No Proper Guidance from Pharmacy Billing Provider

Without getting the proper guidance necessary from a pharmacy billing provider to successfully conduct pharmacy medical billing, a pharmacy will struggle to be fully reimbursed for the provided care and services.

Additionally, the shortage in resources to focus on medical billing within a pharmacy leads to a lack of pharmacy reimbursement.

While hospitals and other healthcare providers typically have full-time positions that manage medical billing and coding complexities, pharmacies manage billing without the expertise of dedicated professionals.

Changes to the Pharmacy Industry Landscape

The role of a pharmacy is integral to modern communities. This was only emphasized throughout the continuous COVID-19 vaccination efforts across the United States with over 258 million doses of the authorized COVID-19 vaccine being administered by pharmacies as of July 2022.

The pharmaceutical industry has seen major shifts in recent years, and these landscape adjustments have led to changing roles and new tasks and challenges for the pharmacy employees themselves.

9 Steps to Implement for Successful Clinical Services Reimbursement

Clinical services from pharmacies are not just helpful - these services are essential to American families.

With Americans identifying the cost of healthcare as the most important financial problem that their family faces, pharmacies have stepped up to help face that challenge.

CVS Health has promised 80% lower costs at their clinics than emergency rooms

Big name traditional pharmacies such as CVS Health have been a part of this pharmacy pivot, and have committed to providing an average of 80% lower cost of care compared to emergency room service.

Providing more affordable care is a victory for all - and implementing these 9 steps for pharmacy medical billing will help your pharmacy have healthier revenue cycle management while doing it.

Understand the Basics of Pharmacy Medical Billing and Reimbursement

To achieve successful reimbursements for care provided, pharmacies must first learn the basics. Having a strong foundation of the medical billing process and codes are vital to successful reimbursements. Our article about Pharmacy Medical Billing 101 shares some of these key learnings to kickstart your pharmacy team’s knowledge.

The Pharmacy Times shared an expert discussion with Melissa Somma McGivney, professor and associate dean for community partnerships at the University of Pittsburgh School of Pharmacy. This discussion shares best practices when it comes to both pharmacy billing and pharmacy medical billing to help demystify some of the common challenges.

American Pharmacists' Association Overview of Pharmacy Billing Best Practices

Develop a System for Tracking Services Provided

Pharmacies need to develop a method to keep track of what services were provided to which patients. This system must serve the pharmacy’s unique needs and enable the pharmacy to easily keep track of all documentation for all services provided while also supporting medical billing.

Creating a consistent system adopted across all pharmacy employees is necessary to keep accurate records. By keeping track of all services provided, it will then be easier to determine which services have been reimbursed, and which ones have not and need to be followed up on.

Create a Process for Submitting Claims to Insurance Companies

Once the basics of medical billing are understood and there is a strong service tracking system in place, a templatized process for submitting insurance claims makes a huge difference. This template should be created according to best practices, and make it easier and faster to submit claims so that claims are submitted in a uniform manner.

It’s much more likely for claims to be accepted if they are submitted properly the first time around. Denied claims are expensive, and they cost pharmacies resources, time, and cash.

MGMA data on cost concerns in healthcare

90% of medical practices shared that costs have risen faster than revenues in 2022. With increasing costs being a concern of healthcare practices of all types, ensuring pharmacy claims are approved the first time around is more important now than ever - and an accurate template is the best way to do it.

NCDS SOLUTION: Processing claims through medical billing is a different process than submitting claims to the PBM. NCDS provides the proper claim edits, formats and channels for sending claims to the payers with all the current ANSI X12 standards so claims are paid properly and timely with no technical errors or issues to interrupt reimbursement.

Stay Up-To-Date on Changes in Reimbursement Policies

Insurance reimbursement policies regularly change and often lack standardization. These changes create uncertainty around when payments will be provided for care that has already been given and can lead to cash flow deficits if a pharmacy is not prepared and aware of the changes being made.

Keeping updated on reimbursement policies will keep your pharmacy prepared and ready to maintain a healthy revenue cycle throughout these changes.

NCDS SOLUTION: Understanding the rules for medical billing can be complex and overwhelming. The NCDS team knows where to find the right resources and applicable regulations so you are able to navigate seamlessly through the medical policies and requirements to ensure you're providing reimbursable services in a compliant manner.

Maintain Accurate Patient Records

One of the most frequent but easily resolved reasons for denied claims is inaccurate patient information. By ensuring patients are regularly updating their records and verifying their information every visit, your percentage of clean claims will increase.

Always verify patient information and have them confirm or update their health plan and contact details. Small mistakes and inaccuracies can lead to unfulfilled revenue.

Use Appropriate Coding for Clinical Services

Medical billing and pharmacy billing have a different set of coding procedures. Medical billing uses a different set of codes than pharmacy billing.

In order to properly submit claims, pharmacists will need to learn and apply the Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) to submit a bill to patients’ insurance plans.

NCDS SOLUTION: The NCDS team is comprised of Certified Professional Coders, Certified Coding Specialist and Certified Medical Coder who are assisted by additional on-staff Certified Coding Associates. They are able to understand, analyze and recommend the proper codes for all of your immunizations and medical services so claims are billed accurately for the care provided.

Provide Educational Training Opportunities for Pharmacy Staff Members

With a lack of understanding of the medical billing process being a major barrier to receiving reimbursement for clinical services, training the entire pharmacy staff on medical billing is a critical step.

By ensuring that pharmacy staff completes training that teaches the ins and outs of medical billing, pharmacies can have confidence that it has a staff well-equipped to be fully reimbursed for the services provided. Pharmacy technicians are particularly important candidates for this training.

A few areas of training that are vital to receiving medical care reimbursement:

• Documentation and authorization steps
• Requirements for claims submissions and templatized submission forms
• Insurance provider reimbursement policies
• Billable professional services
• Medical billing codes

Follow Up on Denied or Underpaid Claims

As mentioned previously, denials are a huge cause of revenue loss for all types of medical practices. Denials and underpaid claims represent revenue for care that has already been provided, but has not been fully paid for.

If a claim is not paid in full, or a claim is denied, this should not be the end of the road. Follow up with the payer to get the full payment, and resubmit denied claims with any necessary adjustments in order to get full reimbursement.

NCDS SOLUTION: Time is money in the revenue cycle. NCDS uses a proprietary Receivables Management Task system to identify, prioritize, track, and analyze denials to optimize the efforts of billing teams to produce the highest value results and feed our database to build deeper business intelligence to reduce and eliminate future denials.

Take Action to Optimize Revenue Cycle Management

Once all of the prior 8 steps are implemented within your pharmacy, be sure to regularly assess and optimize your revenue cycle management.

Taking a step back to analyze how your revenue cycle management performs with your new medical billing procedures helps to tighten up any areas that could use improvement. The following are great questions to ask when reviewing your RCM:

• What causes the most denials?
• Are pharmacy/medical claims submitted in a uniform template?
• How successful are our denial resubmissions?
• How long does it typically take to receive successful reimbursement?
• Has our reimbursement rate increased?

NCDS SOLUTION: NCDS is a hands-on business partner assisting you throughout the medical billing process as well as providing ongoing consultations, reporting and analysis that will keep you dialed-in to the details of your results without all the extra work that would take you away from your primary responsibilities at the pharmacy.

Taking these 9 steps help to get pharmacists on the right path to receiving successful reimbursement from payers for care provided.

With pharmacies taking on many new responsibilities in the modern environment, our goal at NCDS Medical Billing is to make pharmacy medical billing as seamless and successful as possible.

If you want expert advice on how to best handle your pharmacy's billing needs, contact NCDS Medical Billing today.

Questions?