If you don’t have creditable coverage, you may want to join a Medicare drug plan now to avoid the Part D late enrollment penalty, even if you don’t use a lot of prescription drugs. People who have and keep creditable prescription drug coverage, or who get Extra Help to pay for their prescriptions don’t have to pay this penalty.

How do I know if my prescription drug coverage is “creditable”?

Your drug plan must tell you each year if your drug coverage is considered creditable coverage. They may send you this information in a letter or draw your attention to it in a newsletter or other piece of correspondence. Keep this information, because you may need it if you join a Medicare drug plan later and want to avoid the Part D late enrollment penalty. If you have creditable prescription drug coverage when you first become eligible for Medicare, generally you can keep it without paying the late enrollment penalty if you sign up for Part D later.

The cost of the late enrollment penalty depends on how long you went without Part D or creditable prescription drug coverage. In general, you’ll have to pay this penalty for as long as you have a Medicare drug plan.

How much is the Part D penalty?

The cost of the late enrollment penalty depends on how long you went without Part D or creditable prescription drug coverage.

Medicare calculates the penalty by multiplying 1% of the “national base beneficiary premium” ($32.74 in 2020, $33.06 in 2021) times the number of full, uncovered months you didn’t have Part D or creditable coverage. The monthly premium is rounded to the nearest $.10 and added to your monthly Part D premium.

How to avoid the Part D late enrollment penalty?

Join a Medicare drug plan when you’re first eligible.

You won’t have to pay a Part D late enrollment penalty, even if you’ve never had prescription drug coverage before.

Don’t go 63 days or more in a row without Medicare prescription drug coverage or other creditable drug coverage.

Creditable prescription drug coverage could include drug coverage from a current or former employer or union, TRICARE, Indian Health Service, the Department of Veterans Affairs, CHAMPVA, or health insurance coverage. Your prescription drug plan must tell you each year if your drug coverage is creditable coverage. They may send you this information in a letter or draw your attention to it in a newsletter or other piece of correspondence. Keep this information because you may need it if you join a Medicare drug plan later and want to avoid the Part D late enrollment penalty.

Keep records showing when you had creditable drug coverage, and tell your plan about it.

When you join a Medicare drug plan, the plan will check to see if you had creditable drug coverage for 63 days or more in a row. If the plan believes you didn’t, it will send you a letter with a form asking about any drug coverage you had. To avoid a Part D penalty, complete the form and return it to your drug plan by the deadline in the letter. If you don’t tell the plan about your creditable drug coverage, you may have to pay a Medicare Part D late enrollment penalty.

Sources and learn more

Learn how the Part D late enrollment penalty is calculated?

About Medical Billers and Coders

We are catering to more than 40 specialties, Medical Billers and Coders (MBC) is proficient in handling services that range from revenue cycle management to ICD-10 testing solutions. The main goal of our organization is to assist physicians looking for billers and coders.

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In order to chase the distribution of medication as part of your job, it is required to have knowledge about the different processes involved in dispensing medication. Nevertheless, there are other specific features that should be implemented properly, which may impact reimbursement and therefore the Revenue Cycle Management (RCM) process.

Here are some of the key points to remember about pharmacy billing and reimbursement:

Drug Price

Drug prices depend on market dynamics like any other product. Nevertheless, there are some corridors through which drugs can be procured at lesser prices. For instance, hospitals may purchase drugs at a greater price than they are being paid by fixed-fee payers. There are options like low-cost generic medicines which are not even considered. In order to achieve economies of scale, you can conduct price research on a day to day basis and match drugs expending to reimbursement.

Procurement

Procurement is the step where information travels from referring to bought quantities and pricing to designating inventory costs and units of measure (UoM). In most of the scenarios, data is entered manually. Moreover, figures that are uploaded from a wholesale distributor to the system of a pharmacy are too monitored manually in order to avoid mistakes. Transferring data can generate errors which can impact on the revenue cycle management negatively.

Coding

One of the key points about pharmacy billing and reimbursement to prevent costly mistakes is coding. Drugs require to possess correct HCPCS coding and showcased accurately in the chargemaster. Failure in doing so result in the pharmacy not getting proper reimbursement.

Data Workflow

Identifying how the revenue cycle runs in pharmacy is very important. Understanding about pharmacy billing and process management about revenue and expenses of pharmacies is essential. Furthermore, it is vital for sustainable dispensing programs and growth.

Initiating from procurement to inventory and then billing and reimbursement includes buying medications, their storage, and type of distribution, how they are managed, a technique they are billed and coded, and finally reimbursed. All information should be entered accurately to escape costly and time-consuming errors that ultimately impact the revenue cycle.

Rules, Regulations, and Compliances

Maintaining a record of continuous changes to drug-related CMS regulations is a current challenge, which leads to compliance as well as reimbursement risk. According to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) pharmacists will get compensation for medication therapy management (MTM) services from Medicare Part D prescription drug plans.

Alternatives for continuous reimbursement and billing were restricted for the pharmacist before MMA. As a result of MMA, the Current Procedural Terminology (CPT) codes allocated especially for pharmacists playing MTM were designed. Pharmacies should incorporate both the NPI as well as the NPI of the prescriber on all claims.

Linkages between Purchases and Billing

Many hospitals have dedicated processes for ordering and supervising of drugs followed by reimbursement. Without a connection between pharmacy expenses for medication and the chargemaster, confirming appropriate charge capture and minimum reimbursement is a challenge. Apart from this, hospitals should possess automated tools for specifically recognizing charge capture, so as to identify where and when their occurrence to lowering revenue loss.

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Of note, this price is independent of insurance payment, so if an insurance company rejects the claim and it needs to be reprocessed the switch fee will be charged again. Switches (and other companies) also offer a variety of services that are bundled in one package to improve a pharmacy’s reimbursement and reduce exposure to liability.

These are collectively known as pre and post edits (PPE), and examples include:

• AWP resubmission:

  Average Wholesale Prices (AWP) will fluctuate on a regular basis. Unfortunately, if a pharmacy is only updating its drug record files in the computer system weekly or monthly, in times of rising drug costs they will submit an AWP to the insurance company that is lower than the current AWP of the medication. Often this can result in underpayment of claims; in order to correct this, the switch will automatically check for differences in AWP and resubmit with the higher AWP when there is a difference to maximize reimbursement.

• DAW Code validation:

  Dispense as Written (DAW) codes are most often used to specify reasons to the insurance company why a branded medication was dispensed; the default, DAW 0, means that there was no product selection indicated. Other examples include a) the physician wrote brand name only, b) the patient wanted the brand name, c) the generic was not available on the marketplace, or 4) brand drug mandated by law. If a DAW code is selected that is inconsistent with the product chosen (ex. brand selected but DAW 0 used), the switch can reject that claim before it gets to the insurance company to avoid auditing issues.

• Quantity and days’ supply validation:

  Checks for errors in days’ supply based on the product and quantity entered. A common example includes entering the wrong quantity for inhalers (entering it in the pharmacy software system as ‘1,’ when the correct quantity is the number of grams).

• DEA Verification:

  The switch will automatically verify a prescriber’s DEA number to ensure it is valid and in good standing.

• NPI verification:

  As with the DEA number, the switch will also validate the prescriber’s National Provider Identifier (NPI) and can send the claim back if it is not valid. Options to obtain the correct NPI include either calling the prescriber’s office or using the NPI.

• NDC verification:

  This service will check for discontinued or outdated National Drug Codes (NDC’s) and reject the claim so that it can be resubmitted with a valid NDC.

If a patient is Medicare Part D eligible but is either unsure of coverage or does not have their coverage information with them the pharmacy can send an eligibility verification request, called an E1 transaction, through a Medicare Part D Transaction Facilitator (or just facilitator). The facilitator will check the Medicare database and return eligibility information to the pharmacy if there is a match.

Another relevant service the facilitator provides is to transfer the amount spent towards a patient’s True Out of Pocket Costs (TrOOP) to another insurance company in the event the patient switches plans in the middle of the year. It is important to note that if a patient does switch plans mid-year, all the TrOOP costs they have incurred so far in the year will be transferred to the new company – they do not need to start over again.

Finally, after the claim is submitted by the pharmacy, sent to the switch, and possibly sent through the Medicare Part D Facilitator, it arrives at the payer. Once the payer receives the claim it will make a coverage determination and send the claim back to the switch, where it ultimately gets routed back to the pharmacy. Payers generally also charge a fee, in addition to the fee charged by the switch, to process each claim submitted.

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While terms vary among co-pay cards, the manufacturers do not usually allow this because they will then not be reimbursed anything for the medications. Under their ideal scenario, the manufacturers make money because they only pay the pharmacy the difference between the patient’s co-pay without the voucher and the advertised co-pay on the voucher and are then able to sell more of their medication at a high cost, which the insurer pays for. For example, if a manufacturer sells a medication for $500 and offers the patient a coupon that will pay up to $75 of their co-pay, then they will still gross $425 from the sale of that medication.

In providing coupons, manufacturers are able to influence the tiered formulary intended to discourage the use of more expensive medications and increase the sales of their own products at an increased cost the patient does not see upfront. They also increase drug costs by weakening the negotiating leverage that Pharmacy Benefit Managers (PBM) have with manufacturers when setting up their formulary. Because the reimbursement provided to the pharmacy is considered a kickback, co-pay cards cannot be used with government-funded insurance plans.

On the other hand, for many brand-name medications, there is no suitable alternative; one analysis found that out of the 200 highest-expenditure medications 51% had either no substitute or only another branded substitute. In those cases, coupons are of enormous benefit to the patient and allow them access to a medication they would not otherwise have access to. As a community pharmacist part of our job is ensuring adherence and often coupons are a critical tool for us in doing so.

Many patients are not aware that coupons exist for the medications they are already on and so they can be an easy way to provide excellent service, build loyalty at your pharmacy, and relieve the patient of high co-pays. One of the author’s favorite things to do when there is downtime is to browse through the will-call section of the pharmacy, find prescriptions that are eligible for coupons, and bill those coupons before the patient comes. It is very rewarding to see how delighted the patient is when they arrive at the pharmacy expecting a high co-pay and instead pay nothing or very little for their medication.

Another type of manufacturer voucher is a free trial card. While they also might encourage patients to utilize more expensive medications, they allow time for the pharmacist and physician to determine the next steps for the patient without an interruption in therapy. Such steps could include finding a suitable alternative to the prescribed medication, helping the patient apply for a patient assistance program, or obtaining a Prior Authorization if that option is available. It is also preferable to samples being provided by the manufacturer because it allows the pharmacist a chance to perform the clinical checks for appropriateness and drug interactions.

Even with a free trial, it is best practice to run the claim through the patient’s insurance first to determine coverage and then run the free trial. If the claim is rejected or too high of a co-pay through the primary insurance, the pharmacist and physician can work to decide if coverage needs to be worked on for the prescribed medication (prior authorization or tier exception, for example) or if the patient needs to be switched to a different medication.

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Insurance company audits can present a significant financial risk to the pharmacy. In the case there is missing information or a missing prescription, insurance companies can chargeback the entire reimbursed amount of the medication.

Some of the most common reasons for a chargeback include:

• billing an incorrect days’ supply,
• failing to document the billed DAW code,
• failing to have adequate documentation of either the prescription or proof of pickup,
• improper documentation of override codes used, or
• inadequate directions for use.

Common mistakes include:

Topicals:

Prescriptions still come across quite often with directions of “Apply to Affected Areas” for topicals. Unfortunately, these directions are unclear and put the pharmacy at risk for a chargeback. Directions should include the area that the patient is to apply the topical medication to and how often. One method to determine how much cream will be used for each application is the fingertip unit, which is the amount of medicine that will stretch from the end of an adult finger to the first joint and is estimated at 0.5g for an average male and 0.4g for an average female. This figure is then multiplied by the estimated number of fingertip units necessary to cover various areas of the body to arrive at a total days’ supply for the medication. Also, remember that some medications, such as diclofenac 1% gel or Santyl (collagenase), need to be dosed exactly.

Diabetic testing supplies, insulin syringes, and pen needles:

Probably the most common package size for lancets, testing strips, and either pen needles or syringes is 100 count; unfortunately, this quantity doesn’t translate well into 30- or 90-day supplies. A common auditing issue arises when a patient is testing blood glucose, for example, three times daily and the claim is submitted with a 100-count box of testing strips for a 30 day supply. Because this is a 90-day supply and a smaller box is available, a 50-count box of testing strips should have been dispensed. In the case that a smaller box is unavailable (i.e. most lancets), it is acceptable to bill a 100-count box for 30 days because the package cannot be broken.

Inhalers:

The total number of puffs in the inhaler should be divided by the total maximum puffs the patient could use per day. For example, for ProAir or Ventolin (200 puffs per inhaler), a prescription is written as “1-2 puffs PO q4-6 hours PRN” should be submitted as 200 puffs/12 puffs per day= 16 or 17 day supply. If this is mistakenly submitted as a 30 day supply the patient could run out of medication before the insurance company will pay for a refill.

Injectables:

Computer systems often express the total quantity in milliliters, not in the number of syringes. For example, enoxaparin 30mg/0.3mL, #9 syringes, would be submitted as 2.7, not 9. The volume of liquid in each syringe (0.3mL) x the total number of syringes (9) = the total quantity for claim submission (2.7mL).

Eye drops:

Twenty drops per milliliter is a very common estimation to use when calculating eye drops. Also, consider whether the patient is using the medication in one or both eyes when performing the calculation; if it is unclear from the prescription, contact the provider to clarify.

Beyond-use dating:

There are numerous medications that have limited beyond-use dating and the limited dating needs to be taken into consideration when calculating days supply. Lantus, for example, is only stable for 28 days once it is removed from the refrigerator50; if the patient is receiving one vial (1000 units) and using 10 units per day, the correct days’ supply is still 28 days.

Other common auditing issues

Improper DAW Code Submitted:

As stated previously, pre and post edits can assist in catching this error, but many pharmacies get chargebacks because of improper documentation of a DAW 2 (patient requests brand). If the patient does ask for brand and DAW 2 is submitted, a statement to that effect must be on the face of the hardcopy.

Lack of adequate record keeping:

The payer will ask to see both the prescription and the proof of pickup for the prescription. If either of those is missing a chargeback could occur.

Lack of documentation of override codes:

There are numerous overrides a pharmacist can use to receive a paid claim through the pharmacy software system, and if those are not properly documented the payer can issue a chargeback. DUR codes are a good example – you cannot enter M0 “Prescriber Consulted” and 1B “Filled prescription as is” if you have not spoken with the physician and documented that conversation.

Having a discussion with the physician about the risks and benefits of prescription drug therapy (the conversation that would be documented with an M0) is not a delegable task in most states. Even in the case another DUR override code is used – for example, R0 “Pharmacist consulted other sources” – this implies that a reference of some sort was used to determine the appropriateness of therapy. This is also not a delegable task. Delegating this task to a pharmacy technician presents not only auditing issues but safety issues for the patient and legal issues for the pharmacy and pharmacist.

Other clinical rejections provided by the pharmacy software system should also only be overridden by pharmacists, and it is important that the technician alert the pharmacist to it when it is noticed; ideally, the computer system would be designed so that only pharmacists can override clinical rejections.

The following are examples of overrides that necessitate some level of judgment about appropriateness or safety of therapy and should be left to the pharmacist:

Minimum/Maximum doses per day exceeded:

Software systems are designed to alert the pharmacist to an unusual dose; a good example would be Brilinta (ticagrelor) dosed once daily rather than the suggested twice-daily dosing or Remeron (mirtazapine) dosed three times daily which exceeds typical dosing intervals.

Lookalike/sound-alike:

Most pre and post edit services have rejections related to medication safety. A common one is “look-alike sound-alike (LASA)” to ensure the correct medication is being filled and is overridden with a 6666 in the Prior Authorization (PA) field. For legal, safety, and liability reasons, this rejection should only be overridden by pharmacists.

Drug interactions:

Most software systems are designed not to allow technicians to override drug interactions but, in the case a system is not, drug interactions should never be overridden by technicians.

A best practice is to maintain a compliance binder in the pharmacy that has all documentation necessary for auditing and inspection purposes. It should contain locations of all records that are too large to keep in a binder (invoices, etc.). Examples of records are copies of licenses (originals should be displayed), liability insurance, CMEA Self-Attestation (Combat Methamphetamine Epidemic Act), any state-specific requirements, and policies and procedures. It should also provide contact information for the pharmacy manager. In doing so, even if an auditor or inspector comes while a new and/or float pharmacist is there, they will know where all records are.

The post Maximizing Reimbursement and Minimizing Liability by Using Pharmacy Audit appeared first on Pharmacy billing and coding blogs.

The pharmacy department factually is one of the hospital’s greatest revenue generator centers. However, the pharmacy can also be a major contributor to revenue with little upfront investment. Consider hiring a pharmacy billing service provider which can provide support services to decrease the length of stay, manage medication through collaborative practices, and facilitate appropriate medication reimbursement.

Capturing full and appropriate reimbursement in the pharmacy is challenging. Frequent pricing changes, new drugs introduced to the market, outdated charge description masters CDM and missed charge capture can contribute to missed pharmacy revenue.

However, pharmacy also presents ample opportunity to streamline processes and enhance revenue to drive the bottom line.

Below Are Revenue Capture Methods To Proliferate Pharmacy Billing

1. At times, data integrity is the greatest barrier to improved pharmacy revenue capture, for example, making sure bills should have the correct national drug code is critical to proper coding, charge capture, and reporting.

Other data-related challenges include incorrect coding of drugs procedure and revenue codes, incorrect multipliers determine billing units charged, and improperly reconciling pharmacy purchasing data with charge capture data.

2. Eliminating data errors should be a top priority for pharmacy, operations, and revenue cycle leaders. Implementing an effective charge capture process by hiring a pharmacy billing management service that helps in bridging the data gaps can help improve pharmacy revenue capture. Three ways to improve data integrity are:

• Integrate pharmacy data, including purchase history, formulary, CDM, and pricing data
• Update CDM information
• Establish a governance structure for ongoing review and maintenance

3. By making a few upfront investments, health system leaders can see significant ROI in terms of increased pharmacy revenue and improved compliance. It is recommended for the organizations to invest in the following manner:

• Using the latest technology and tools to support pharmacy, operations, and revenue cycle staff in proactively identifying and correcting issues during charge capture.
• Linking the pharmacy medical billing service system with the organization’s billing system to streamline reconciliation and swiftly identifies and disconnects inventory and charges.
• Creating a multidisciplinary management team of representatives from pharmacy, finance, and clinical staff to monitor and maintain processes, such as timeliness of CDM changes, effective communication plans, and quality checks for accuracy.

Final Thoughts

Today is all over mentioned and it’s very challenging that the political and regulatory environment is putting pressure on hospital finances. Health care centers, clinics, and hospitals are struggling to maintain positive operating margins amid decreasing government reimbursement, increasing drug prices, and growing drug shortages, and the rising cost of care.

As drugs account for a significant portion of hospital spending, pharmacy plays an important role in a health system’s financial performance. As such, improving pharmacy revenue capture through various revenue enhancement services like outsource pharmacy billing to a professional vendor can have an outsized effect on an organization’s bottom line.

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In this article, we discuss the ways in which revenues can be enhanced by way of patient communication especially when there have been cases of dissatisfaction where patients have had to wait for prescriptions at least one-fourth of the time.

1. Verbal Communication: Effective communication implies that the pharmacist must be slow and steady while explaining the patient about the medication. The pharmacist must encourage the patient to ask questions and clear any doubts the patient might have. Further, they should ask the patient about when would the patient take the medication, in what amounts and at what times, keeping which precautions in mind. This would ensure the pharmacist that the patient has understood. The patient can also be provided a pill card or a medicine box with compartments to keep their daily medication. If the patient is satisfied, they will return to the same pharmacist for assistance enhancing the pharmacist’s revenues.
2. Patient Responsibilities: The patients must understand that the pharmacist is there to help them in every way possible. Before going to a pharmacist, they must ensure they have enough time to spend with the pharmacist. They must draw up a list of questions that require to be addressed with utmost care. The patient can discuss the condition of the ailment before and after the treatment and what could be the future outcome. The patient can make notes of the details discussed so as to not forget any aspects later. The pharmacist must advise the patient to always carry their (pharmacist’s) contact details while traveling in case of any issues that may arise and need clarification. With such concerned pharmacists, the patient is sure to visit them again enhancing revenues for the pharmacist.

3. Other Assistance: The patient must inform the pharmacist of other medications they are taking for other ailments so that precautions can be taken for the new medications which the patient might be starting with. Sometimes, a pharmacist can suggest over-the-counter medications or side effects any medications can cause; which can further propel the patient and the pharmacist to together resolve the problem at the earliest. The patient must know from the patient as to what time of the day the medication must be taken, with/without food, and what must be done if the medicine does not work in the assumed time. The patient must ask the duration for which the medication must be taken and if any diet or exercise can help with the medication.
4. Names: The patient must inform the pharmacist about all the ailments in totality. The patient must know the brand and generic names of their medications and their ingredients, and how would the medicine react in their case. This two-way interaction definitely opens up the scenario between the pharmacist and the patient ultimately leading to enhanced revenues for the pharmacist.

The pharmacist must inform the patient about how the medicine must be stored. It is also not advised for a patient to switch pharmacists too often; as it simply adds on work. For one, the new pharmacist will need to be explained the details all over again; two, to keep transferring prescriptions is a great task in itself.

A pharmacist must be carefully chosen who can address the patients’ concerns as much as a medical practitioner can. A patient-centered pharmacy will always detect and remove the low level of health literacy in patients, and ultimately identify opportunities for improvements thereby augmenting revenues.

The post Talk To Me!! How Revenue Could Be Affected By Patient Communication? appeared first on Pharmacy billing and coding blogs.

Here Are A Few Ways In Which Counseling Skills Can Help Augment Pharmacist’s Revenues:

1. Customer Relationships: The pharmacist must form a professional relationship with the patient, albeit with a personal touch. The patient may take the pharmacist as a parent and wish to be treated as authoritative and nurturing. The pharmacist must build this with imparting trustworthy information and care. The patient will definitely go back to the same pharmacist who takes out time to talk to them than one who just passes medicines on without any explanation.

2. Service: While counseling patients on how and when the medications are to be taken, it is recommended that pharmacists add on a service of sending alerts/messages to the patient about their medication. This will make the patient feel important and the patient will then return to the same pharmacist thereby increasing the pharmacist’s revenues.

3. Effective Communication: This would be one of deal maker or breaker between the pharmacist and the patient. The patients need to understand what is being communicated; hence the pharmacist must not speak swiftly. The pharmacist must have a clear eye contact, a pleasing personality and be enthusiastic (tone and body language) while dealing with patients.

4. Needs: The pharmacist must also always ask the patient if there’s any more added assistance they need. The conversation between the pharmacist and the patient must revolve around the patient’s requirements. It is vital for the pharmacist to gauge the patient’s response. If the patient is unable to understand, the pharmacist must work around way to explain the medication.

5. Simple and Strong: The counseling skills of the pharmacist must be simple and strong. Apart from explaining with a few basic points, it is imperative that the pharmacist speaks with utmost confidence and conviction.

6. Suggestions: If there has been no discussion with the pharmacist, and the patient goes out with mere directions on the medication label, it simply indicates a void between the two. To clear this, the pharmacist can enquire if the patient is aware of the medication prescribed, how it should be taken and other precautions before administering the medicine. The pharmacist must explain the consequences if a dosage is missed; how can the patient know if the medication is working on them; how the drug works in the body; the allergies associated with the medicine; other medications which the patient is taking/shouldn’t take which might have a good/adverse effect with the current medication being discussed; or have any effect on any other disease that the patient has. The pharmacist must explain the storage system of the medication, what must be done about refills, what must be done of unused meds and that the patient can contact the pharmacist in case of any doubts. The pharmacist must also explain of any Black Box, grapefruit, sun sensitivity or specific alcohol warnings in the medication.

The pharmacist must instruct keeping in mind that the patient has rudimentary education about the medication. Pharmacists can visit the ‘ASHP Guidelines on Pharmacist-Conducted Patient Education and Counseling’ for patient instructions and counseling strategies. The pharmacists must create a strong brand identity and be able to cater to all needs of the patient thereby augmenting their revenues.

Clear counseling. Strong relationships. Better revenue.

Let MBC help streamline your pharmacy billing so your focus stays where it should—on your patients.

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Sorting Pharmacy Front Desk

Most generally patient handling can put stress on any medication dispensing unit. Hiring a Pharmacy Billing Specialist can be synonyms to a smooth running business, without any disruptions. This is because they capture patient details like making a record of their reports, prescriptions, medical history and other important things. These records serve as overviews of a patient’s physical condition and help them serve better. Being an expert they can easily interpret the medication orders, calculate and compound the dosage, and dispense the medications as required by the doctor. Any patient who gets impressed by the services provided at the pharmacy is likely to become a regular and would also recommend the pharmacy to other acquaintances increasing the customer footfall at the establishment.

To channel business from the repeat customers, the specialists can send timely reminders to them for refills and thus help in maximizing the productivity of the pharmacy.

Tackling Documentation

Processing a medical claim is one lengthy procedure that a Pharmacy Billing Specialist can tackle with this specialized skill set of knowledge. When a patient makes a medical claim, it is required to document the claim properly along with doctor’s details, diagnosis, treatment, reports, patient discharges figures etc. Only an accurately documented record can help in faster medical claim settlement. Thus having a Pharmacy Billing Specialist to tackle the documentation process can be rewarding for any pharmacy.

Proficiency at Billing

Having a billing specialist ensures that each and every service provided to the patients gets recorded and billed accurately. Moreover, following up with the patients and vendors ensure that the payments are received timely. A pharmacy billing specialist is qualified to handle various drug code categories (CPT) and is well versed at coding guidelines and emergency codes issued by the government. Use of correct codes in billing reduces the rate of claim denial a great deal thus growing the revenues of the pharmacy. The specialists are also known to ensure compliance of billing system to the billing regulations that have a reputation of changing time and again.

The post Why are Pharmacy Billing Specialist Important for Maximizing Revenue? appeared first on Pharmacy billing and coding blogs.

With this herculean shift from Fee-for Service Model of Reimbursement to Value Based care Model a change in the Revenue Cycle Management can be expected. Here are the ways the new payment model might affect the financial front of your business:

RCM is going to be more detail Oriented and Demanding

When it comes to value based care patient experience comprises of services more than just clinical care. This requires the office staff to fill in shoes of customer service agents in order to manage the patient intake in such a way that the whole treatment experience is profitable for the care seeker. This might involve spending time with each patient to help them understand the details of their treatment, especially in case of recurring patients. Ascending interaction, patient education and assistance when all clubbed together can improve the patient experience dramatically, which will show on your revenues.

RCM Needs Trained Technicians

With Value Based Care model the front end RCM is going to be a little more complex comprising of exercises like collecting the correct patient data before service to evade denials. If the motive is to improve revenue, care providers should emphasize upon eligibility checks, management of co-payments, and collection of patient deductibles. A fitting solution is to hire highly trained clinicians to enable accurate and timely assessment of patient status. This will prevent denials and increase overall efficiency.  

Adopting Bundle Payment Method for Care Cycle is a Gamble for RCM

Bundle Payment Method is believed to work best when it comes to Value Based care that focuses on wholesome care. Bundled payment arrangements are devised to pay multiple healthcare providers for coordinating amongst themselves the total amount of services they provide for a single, predetermined episode of care.

A well formulated Bundle Payment mechanism encourage teamwork as well as runs successful in ensuring high value care of the payer. During an ongoing ‘episode of care’; if the operational cost amounts to less than the predetermined Bundled Payment price than the medical unit can keep the difference. However, if the cost exceeds the set price, the unit may suffer losses. The model is known to prevent providers from financial risk contracts though.

Slow Spending is a Thing

In case of patients that suffer from chronic diseases, such as diabetes and congestive heart failure, the care providers need to spend most of their resources when providing care. This is because their medical condition forces them to be repeatedly admitted into the hospital and frequently visit the care centers. Caring for such patients incur heavy expenses.

To reduce hospitalization and operational costs in such cases, doctors must focus on providing care with a preventative approach. This entails a shift in focus to high value care so as to reduce total-care spending and increase the value of care by omitting chances of unnecessary read missions, and thereby increasing revenue for providers.

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