The Pharmaceutical Care Management Association (PCMA) represents managed care pharmacies, PBMs, and their healthcare partners in pharmaceutical care. PCMA opposes efforts to regulate PBMs.

They believe that various services performed by PBMs (e.g. Internet activities, Mail service pharmacy licensure, Drug utilization review, Claims management) are already appropriately regulated under existing federal and state laws.

According to PCMA, further regulation would unnecessarily interfere with The PBMs’ unique ability to link patients, physicians, and pharmacists it would also increase operating costs for PBMs and reduce their ability to pass on cost savings to consumers. Determining whether a PBM partnership is right for a payer’s needs requires the health plan to weigh up the pros and cons of contracting with a middleman.

The Pharmaceutical Care Management Association (PCMA) believes that PBMs benefit payers through annual drug savings, promotion of generic drugs and cheaper prescription alternatives. They can also help payers facilitate enhanced care delivery.

The Reason That We Need A Better Regulated Pharmacy Benefit Manager Includes:

• This Is A Transparency Bill That Should Keep Pharmacists Better Informed About How PBMs Determine Maximum Allowable Costs (MACs).
• Strengthens Existing MAC Law Enacted In 2013, Attempting To Create Accountability In Prescription Drug Pricing.
• This Law Addresses PBM Registration As A Third Party Administrator And Will Ideally Develop A More Structured Pathway For PBM Enforcement And Oversight.
• This Law Creates A Bill Of Rights To Be Followed For Any Entity Conducting An Audit Of A Pharmacy.
• Requires PBMs To Itemize By Individual Claim The Amount Actually Paid To The Pharmacy Or Pharmacist, And An Identifier Of The Pharmacist Services.
• This Act Preserves The Professional Independence Of A Pharmacist / Pharmacy. Additionally This Act Limits The Retaliatory Actions That A PBM Can Engage In Vis A Vis Pharmacy.
• Regulates How Drugs Can Be Put On The MAC List As Well As Requires The MAC Lists Be Made Available To Pharmacies. The Act Also Requires That Necessary Updates Be Performed On The MAC List Every 7 Days. It Also Creates An Appeals Process For Pharmacies To Dispute MAC Price Billing With PBMs.

PBMs are a type of Middleman Company hired by insurers to negotiate pharmaceutical prices with drug manufacturers and handle insurers pharmacy claims. When a patient with insurance fills a prescription at a pharmacy, the PBM reimburses the pharmacy on the insurer’s behalf.

That gives PBMs enormous leverage over the opaque world of drug pricing and broad power in the health care system generally. The nation’s three leading PBMs — CVS Caremark, Express Scripts and OptumRx — manage prescriptions for 180 million Americans.

Payers that have the populations and resources to contract PBMs may be able to curb unnecessary prescription drug spending, and payers should always review the details of PBM compensation before entering into agreements. But payers that may require an expert partner to help save prescription drug costs stand to benefit from a PBM contract.

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It has been observed that often the dearth of adequate human resource leads to time consuming pharmacy billing practices that make use of manual processing procedures. Staff employed has undefined roles and often lacks knowledge about various drugs and govt. Regulations of maximum dosage and allergy information.

Additionally, decentralized sharing of the data and its processing requires tiresome duplication that increases turnaround time. Moreover, absence of information about pharmacy billing and insurance clauses result in major errors. Thus, we can conclude that pharmacy billing practices require high level of quality control when dealing with steep volumes and strict deadlines.

To reduce costs and improve the bottom line of business, here is a list of five pharmacy billing mistakes that most profitable practices avoid:

Mistake I: Having a Decentralized Billing System

The need for flawless automated systems which can help reduce TAT and allow better efficacies into the business is uncompromised. Profitable practices work with a central IT system to avoid record duplication and ensure a single point for all information. All the data and information about a patient’s treatment, medication, bills processing, insurance details, etc. needs to be accessible through a centralized system with real time updates. Not only does this minimize errors but also ensure better reimbursements.

Mistake II: Absence of Customized Processes

While a highly customized software or process may fall off limits for small individual pharmacies, developing or purchasing software that adapts best to the needs of your organization practices and IT infrastructure is recommended.

Mistake III: Lack of Common Vision

All profitable practices make sure that the roles and responsibilities of different employees in the pharmacy department are well defined. It is effective to communicate to each person the core purpose of the organization and then motivate them enough to work towards it.

Mistake IV: No Stringent Documentation

A concise success strategy of profitable practices is to create a detailed and comprehensive documentation of every patient that comes in. This sheet needs to be continuously updated and should be easily accessible. Clear and concise documentation filing assists in spelling the entire story of the patient clearly welcoming conducive action.

Mistake V:  Inadequate Staff Training and Information

To be best in class when it comes to pharmacy billing, it is important for its processes and people to remain ahead in comparison to their competitors in terms of task, crises management or any other situation. For a pharmacy to have a team that knows the business, it is important to provide cutting edge training resources and user friendly access to all medications and procedure information

that they require in order to provide more efficient services. Additional training may help in enhancing the productivity of employees and allows them to deliver quality services to patients. With the help of prompt updates, automatic refill alerts, early authorization processes, and real-time tracking can help the facility provide superior pharmacy billing services and lead the industry.

In today’s time, ever increasing complexity of healthcare industry that revolves around governmental regulations like additional codes and rules need to be followed with greater care now than ever. Conclusively, unique and valuable services like processing refills before time, working on inconsistencies of data, providing the right information and ensuring timely billing and claims can aid efficient pharmacy revenue cycle management.

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In 2014, prescription drug costs were around 9.8% of total annual heath care expenditure, with total prescription drug spending accounting for $297.7 billion, the 12.2% increase over 2013.  Now to hold the cost of a drug down, many private employers, insurers and federal government are using Pharmacy Benefit Manager (PBM). PBMs are third party administration for a prescription drug with over 266 million Americans i.e. approx.82% of the total U.S. population are covered under the commercial healthcare plans.

Pharmacy Benefit Manager evolved and first become popular in the early 1970s. The initial stage of PBM used the complex business model to manage prescription drugs, however today they are more popular for the services of healthcare insurance companies and drug program service for employers. PBM has negotiated the costing from drug manufacturers and discount from retail pharmacies. The main part of PBM is providing the patients with affordable pharmacy channels and effective delivery channel. PBM had encouraged the efficient processing of claims and improve patient compliance with high-cost specialty medications.

In 2015, the report of National Community Pharmacists Association identified three legislative and regulatory concerns

1. Lack of accuracy and transparency in PBM revenue streams.
2. The conflict between retail pharmacy and specialty pharmacies.
3. Unclear generic drug pricing.
4. Maximum allowable cost payment calculation.

Pharmaceutical manufacturers are not pleased with the emergence of PBMs since much of the savings they generate is from the drug maker. The political scrutiny on pricing has increased over the past years. According to the pharmaceutical manufactures main problem lies with coverage and not pricing.  They have three basic arguments from their side.

1. Coverage providers implement the cost sharing strategies to restrict the rise of premiums. The manufacturers argue that rising price of drugs is mainly due to coverage providers.
2. PBM – “Middle Men” the pricing problems seem to have greatly been because of them. The generic drug supply and specialty drug supply is regulated through middlemen.
3. Drug companies criticize the health plans for not using various manufacturing rebates on the generic drug. This will cover the cost-sharing expenses for each drug as it is dispensed at the pharmacy counter.

PBMs main focus has been to reduce the cost of drugs for both clients and consumers. This is the reason also that the PBMs always promote generic drugs over other brands of drugs. The large hiring of PBM from Fortune-500 companies, labor unions, and government plans like Medicare Part D reduce overall pharmacy cost. The above incentives are far greater than the rebates paid by the Pharmaceutical manufacturers.

To protect the price rise the best option is promote more competition. The FDA could facilitate this by faster approvals for the bio-similar brands and generics drug.  As Policymakers juggle between reduction in cost and tight laws of approvals- the fundamental problem it solves is the price rise of generic drugs.

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