That’s largely due to the low insurance reimbursement rates middlemen, known as pharmacy benefit managers, or PBMs, pay pharmacies and the fees they charge to pharmacies after drugs are dispensed.

Independent pharmacies are more than 75% of which are located in population centers of 50,000 or less, have been on the decline and represent about 38% of the total retail pharmacy marketplace in USA. The fees/payments are charged on the pharmacies on those drugs covered under Medicare, known as direct and indirect remuneration DIR fees, save the health care system considerable money.

Direct and Indirect Remuneration is a form of performance-based payment used by pharmacy benefit managers to promote value and quality and helps kept premiums down for Medicare beneficiaries. The price concessions that PBMs negotiate with drug manufacturers and drugstores and report to the Centers for Medicare & Medicaid Services as DIR are generating significant savings for the federal government and are projected to save enrollees in standalone

New Reforms Making Pricing More Transparent

When it comes to reimbursements for generic prescription drugs, it may often seem like there’s little rhyme or reason to what is paid. This is unfortunately the case for many independent pharmacies dealing with Pharmacy Benefit Managers.

PBMs, the third party entities that oversee the administrative side of Medicare’s Part D plans, often reimburse independent pharmacies well below their cost in acquiring and dispensing generic prescription drugs.

Considering generic prescription drugs account for 80% of drugs dispensed, underpayments can be a considerable blow to a pharmacy’s bottom line. In an effort to hold PBMs accountable, Ohio Governor John Kasich recently signed into law a bill with amendments regulating how and when PBMs assign drug pricing.

Developing Responsive Solutions

Pharmacy billing programs enable pharmacies to benefit from streamlined processes and improved profitability. They leverage an experienced team to negotiate competitive contract rates, terms and conditions and to provide reimbursement support. With a customized approach to matching each pharmacy’s unique business, they empower our members to stay highly competitive.

Contracting – Let an Experience Team Become A Liaison

Let a pharmacy billing team become your liaison. They negotiate contracts on your behalf to maximize reimbursement opportunity. Their strategy is to increase reimbursements while slowing or eliminating decreasing rates. They leverage our network connections and plan knowledge to help our members attain the highest level of profitability. They negotiate retail, Medicare, Medicaid, long-term care, home infusion and specialty network contracts.

Reconciliation

Manage account receivables more simply. Reconciliation is available to all pharmacies and is an industry recognized program for claims tracking. Their service electronically verifies each payment to ensure correct reimbursement. In addition, Reconciliation offers an elite claims chase program to track underpaid and unpaid claims for TPN members. Reconciliation ensures you’re paid the right amount in a timely manner.

Electronic Fund Transferring

Your pharmacy works best if reimbursements are received in a timely fashion. With Electronic Funds Transfers for over 30 payers, pharmacy billing companies have help independent pharmacies to reduce delayed or lost checks and receive reimbursements faster via direct deposit.

Independent pharmacies are enrolled with all of the payers that currently offer EFT, as well as all future plans as they become available. Their dedicated support staff will complete all of the necessary paperwork for you; all you have to do is sign.

Medicare And Medicaid Processing

Through this specialized processing and billing solution, you can submit Part B Medicare claims for eligible durable medical equipment.

The pharmacy billing’s comprehensive suite of solutions will allow your facility to electronically submit vaccines, Medicare Part B and most state Medicaid durable medical equipment claims using your existing pharmacy software system.

The post How Can Independent Pharmacies Deal With Underpayments? appeared first on Pharmacy billing and coding blogs.

In the recent past one the biggest change and challenge pharmacies are facing is the establishment of performance provider networks and the contraction of these networks, where insurance plans are giving their beneficiaries access to a more select network of pharmacies.

Until sometime back, healthcare plans wanted to have broad coverage with as many pharmacies as possible. But now there’s the focus on value-based care rather than fee-for-service models, so health plans are narrowing with fewer pharmacies, particularly those that can prove they are addressing quality measures, delivering care that’s improving the lives of patients, and reducing the overall total cost of care.

• Is Evolvement An Opportunity For Pharmacies In 2018?

In the short-term the changes will be seen as challenges, but in the long term, they are certainly opportunities to evolve. Pharmacy facilities almost always view these changes and initiatives as an additional luggage on their shoulders, with every new program seeming like a heavy weight.

However, these changes can provide pharmacists a clear path to truly changing their practice.

• What Will Happen To Pharmacies That Don’t Start Evolving To Meet Changing Demands?

The cost of running the pharmacy practice and profit margin pressures are going to continue to create real difficulty in the standard pharmacy practice model. As the margins continue to shrink, the pharmacies will be working harder, rather than smarter.

Certainly, there’s always a need for medications to be dispensed, but pharmacies must evolve and be centered on patient-care model.

• Is It So Critical To Achieve Provider Status For Pharmacists?

The goal of provider status is to enable the pharmacist billing to practice at the top of his or her license. Pharmacists are trained for six or seven years on appropriate medication use, but they do so much more than just counting pills, putting them in a bottle, and handing them across the counter.

Pharmacists are the ones who ensure patients are on the right medications, are using them legitimately, and are achieving the desired results with those medications.

Getting provider status passed, and building an effective infrastructure will give pharmacists the ability to use everything in their arsenal to improve patient care. Also, with this evolvement their pharmacy billing structure and medicare part b billing pharmacy shall also improve.

Over and over, we see patients needing access to more comprehensive services. The consequences of suboptimal medication use are astounding right from hospitalizations, to readmissions, to even death.

Pharmacists, who want to evolve in 2018, must understand and change their mindset beyond just filling prescriptions. They should rather move to a patient-centered view where they are looking at all of the patient’s needs when they fill prescriptions. Each prescription fill/refill provides an opportunity to more meaningfully engage the patient.

The post How You Can Evolve Your Pharmacy Practice In 2018? appeared first on Pharmacy billing and coding blogs.

The additional services being offered are the over the counter (OTC) and personal care areas, the pharmacy counter, in specialty procedures and in the prescription pick-up areas. Not only are these wellness services beneficial to pharmacy customers, they also create opportunities for drug/medicine marketers and offer a measurable return on investment.

Evolving Role of a Pharmacists

A few decades back, the traditional role of pharmacists was to solely dispense prescriptions. They were not allowed to discuss medications with patients and had to refer them back to their doctors when questions arose. But, as time passed pharmacists began to supply some very basic information about prescriptions. Today, the tides have changed. Retailers are equipping their pharmacists as never before with the technological tools they need to the provider of enhanced services and to engage with patients.

The increased role of the pharmacist allows for quality interactions, a key component in patient retention and medication adherence. To provide you with an example, recently a pharmacy student who said that his parents only pick up their medications when they know a particular pharmacist is working because they appreciate the way they treat them. This is a sign of the personality component that a well-regarded pharmacy brings to the retail setting and supports the role of pharmacists to become trustworthy advisors who can offer assistance to patients with their health concerns and needs.

Drug stores in the U.S are now giving more time and attention to offering a wide spectrum of wellness services. Screening tests, health programs, vaccinations, clinics and on-site educational events are not only a helpful to consumers, but also establishes the community pharmacy’s value as a wellness clinic. Another developing example of this is the retail clinics within pharmacies. It is estimated that by 2018 the number of retail clinics will double from 1,418 to over 2,900 nationwide. Also, 27% of individuals say they have used retail clinics for medical care and more than 15 million people, on the estimate, have been treated in a walk-in clinic, while 38%-40% of in-store clinic customers will make an OTC purchase.

Expanding Communication Channels

Pharmacies are reciprocating to the need for health data by providing a platform for in-store methods of education and communication. Some of these methods include:

• Data Dispensers on the Shelf
• Prescription Bag Newsletters
• Billing through Professional Pharmacy Billing Companies
• Pharmacy Counter Displays
• Specialty Health Newsletters or Magazines, And
• Digital Screens

By utilizing these methods in their stores, pharmacies have the data available when solutions are required, whether it is in the OTC areas, at the pharmacy counter or elsewhere. As they fulfill the needs of patients who are increasingly more involved in monitoring and managing their health, pharmacies are becoming valuable channels such as a wellness clinic will reach a large and relevant audience.

Why Medical Billers and Coders (MBC)

As we approach the end of year-2017, it might be the time for you to calculate the Account Receivable (AR) for 2017 and have a better approach towards 2018. Medical Billers and Coders hold 17 years of experience in medical Revenue Cycle Management (RCM) with a skilled team coders and billers. Get a quote for your Pharmacy Specialty.

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High reliability organizations are organizations with systems in place that make them exceptionally consistent in accomplishing their goals and avoiding potentially catastrophic errors.

The drive to become high reliable healthcare organization, the industry has come to realize this work will improve our performance in everything they does. It needs focusing on 5 principles:

1. Highly Reliable Healthcare Organizations Are Sensitive To Operations

Based on the understanding of HRO’s operational complexity, resources in HROs make every effort to maintain a high cognizance of operational conditions. This sensitivity is often referred to as big picture understanding or situation awareness which means people tends to cultivate an understanding of the context of the present state of their work in coordination with the unit or organizational state for example- what is going on around them or how the current state might support or threaten safety.

2. Reluctant To Accept Simple Explanations For The Problems

Highly reliable healthcare organizations do identify potential reasons for poor performances, but they never stop there; they continue to analysis further. They ask more questions. They keep digging until find the specific source of the problem is not found.

For instance; people admitted through ED were actually more satisfied than direct admissions. When patients were admitted through ED, they were more likely to be prepared for longer wait times or other operational issues. But patients admitted through a direct referral from their physicians expected a swift and seamless admission process, only to be disappointed when such did not occur.

What’s the lesson? To become high reliable healthcare organizations, hospitals need to dig into their metrics, compare information and question explanations that may seem reasonable or obvious, because the very opposite may be true.

3. Highly Reliable Healthcare Organizations Are Preoccupation With Failure

Each employee at every level in a high reliable healthcare organization is encouraged to think of ways their work processes might break down. This sense of shared attentiveness is persistent. It is applicable to small inefficiencies and major failures, including medical errors. Employees are encouraged to share their concerns for potential failures, which can help create best practices across departments.

Medical errors that are detected and corrected before harming patients are called near-misses; highly reliable healthcare organizations treat these events differently from other hospitals. They encourage employees to come forward with near-misses and they focus on which processes and safeguards work best.

4. Highly Reliable Healthcare Organization Defer To Expertise

Leaders at highly reliable healthcare organizations listen to people who have the most developed knowledge of the task at hand. At times, these individuals might not be senior most person or an experienced on, but they are still encouraged to voice their concerns, ideas and input regardless of hierarchy.

If leaders and supervisors don’t listen to staff about processes and operations within the hospital, it is practically impossible for the organization to develop a culture of high reliability.

5. Highly Reliable Healthcare Organizations Are Resilient

This trait could also be called relentlessness. Leaders are prepared in how to respond to failures and continually find new solutions. They might improvise more, or quickly develop new ways to respond to unexpected events. Highly reliable healthcare organizations might experience numerous failures, but it is their resilience and swift problem solving that prevents catastrophes.

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They often face cost pressures that impact their revenue cycle management. While focusing on various aspects of running a pharmacy and trying to steer traditional profits in the process; a pharmacist might overlook the importance of recouping the maximum on insurance reimbursement claims.

Stabilizing the cost and obtaining fair margins are important for revolutionizing the pharmacy reimbursement system. Most pharmacies are marred by reduction in reimbursements due to the inflation of generic drugs. However, here is an exhaustive list of ways through which a pharmacy can shoot up the reimbursements they get for medications they dispense:

Keep a Check on U & C Price Points

It is common knowledge that payers often neglect updating their pricing as often as wholesalers or pharmacies do. Hence, there are chances that they are paying reimbursements based on older pricing that is outdated. With the help of technology fortify your pharmacy management software to point out such discrepancies. It should highlight all the payments that were paid at Usual and Customary (U & C), implying that you were paid in full.

Be Accurate With DAW Claim Codes

Dispense as Written Codes (DAW) are of importance in dispensing prescriptions in a pharmacy. These are simple codes comprising of one or two digit that indicate important information to the pharmacist. These Dispense as Written codes were introduced to formulate a standard method of denoting why a pharmacist used or did not use a certain brand of drug.

In the view of availability of similar drugs from multiple wholesale companies and other sources, these DAW Codes help attain a level of transparency, clearly indicating why a drug is being dispensed over other similar options. These codes help medical insurance companies and pharmacy benefit managers in organizing claims and determine prescription coverage.

Being inattentive with DAW codes can negatively affect the profitability and efficiency of your pharmacy; as the reimbursements will be inaccurate. In these cases the pharmacy will also lose time over claim re submission and may invite a pharmacy audit.

Update AWP Information

The reimbursements made by Insurance companies to pharmacies are most generally based on the average wholesale price (AWP). However, these third party payers seldom have the most up-to-date AWP prices loaded in their system when you bill.

This can be a major reason of discrepancy in third-party reimbursement and needs to be carefully monitored. Pharmacy owners need to make sure that their software is updated daily and with the latest pricing information.

Track Reimbursement Compliance

It is a trend that when a drug manufacturer raises the price for its medications, pharmacy benefit managers (PBMs) and payers are slow in updating the maximum allowable cost (MAC). The result is that pharmacies are reimbursed at a very less acquisition cost. On the other hand when the cost of the drug goes down, PBMs are quick to update the MAC list, to over-reimbursing their pharmacies at all costs.

It is thus important for pharmacies to track compliance of reimbursements from PBMs for patients that have been served. It is important that they are reimbursed at the correct contract rates.

Best strategy would be to compare the reimbursements that pharmacies get from various payers and PBMs against Maximum Allowable Cost (MAC) levels. By employing the right analytical solution, this can be done right.

Focus On Favorable Contracts

They key to increasing pharmacy reimbursements is putting all the information in one place to compare.  By linking together contracts against plans and patient medication adherence, pharmacy can generate valuable big data about contracts based on volume, adherence patterns, PBM compliance behavior and other factors.

This knowledge provides full picture of the health of the pharmacy business and its performance. Pharmacies can then enter negotiations with PBMs and insurance providers with refurbished ability to enter into favorable contracts terms in future.

Maximize your pharmacy’s reimbursement potential with expert-driven strategies. Partner with Medical Billers and Coders to streamline billing, reduce denials, and secure stronger financial outcomes. Schedule your consultation today!

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The job just became more compounded with the pharmacy claim process.  Pharmacy billing has come to the forefront with increased regulations on the drugs prescribed and sold.

The rules and regulation have made it important for the pharmacist to maintain a medical ledger where all the medical bills and claims are registered in the proper format. This has made the process cumbersome for a pharmacist looking to serve people.  A pharmacy billing process requires a long documentation and constant monitoring with insurers to settle the claim. Now a pharmacist working on a medical solution will need an extra hand. Now you have two options,

Hire an In-house team of coders and billers or outsource medical billing.

Here are some factors you should consider before making a decision:

1. Admittance

The first step towards revenue generation involves capturing the medical history, previous prescription, previous doctors, insurance details, billing details etc. This will require many calls back and forth to different medical departments. If the process is outsourced to a team of experts who are tasked with every step this will make the admittance error free; with an in-house billers and coders the process will become complex with several patients visiting the pharmacy.

2. Prior authorization

Prior authorization is one of the most important factor in the modern day healthcare system. When a patient is diagnosed with a disease which requires two different specialties to work together you will also need an approval from the insurer before providing the drug.  The drug can have certain side effects when combined with other drugs to prevent such risks we need a good prior authorization.  An outhouse team of experts will explicitly sort the drug issue.

3. Refill management

Refill management is a golden step for a pharmacy for customer retention. Regular customers are impatient and look for other options if not satisfied with service of the current pharmacy. You need to have a proper refill management system to track the patients and provide them with a reminder when necessary. With outsource, you can task this to software which can track all the refills without any manual interference.

4. Follow-up

Every service needs to get billed to generate revenue an outhouse team will accurately document and maintain records without you depending on the single person. The balance and billable need to be maintained properly to avoid goof-ups. An outsource team will follow-up with insurer or patients on regular basis with regards to payments and refill. With an in-house team, the detailing can become tedious with every new patient added.

At MBC we help pharmacist easily track their account receivables without any nuisance of calling the accounts department. The pharmacist will be billed according to the claims settled by the MBC, so no extra charge on hiring and software’s.

The important aspect looking at pharmacy billing is to have proper documentation with each and every step. At medicalbillersandcoders.com, we provide end to end pharmacy billing service. Reducing the data entry at different points and make a proper payment channel. We will ensure that you have a proper reimbursement at the properly accounted time.

Medical Billers and Coders is one of the most trusted and reputed name in the medical billing industry. Deploying customized solution for pharmacy billing after understanding your needs.

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MBC launches customized insurance verification services for pharmacy billing providers, helping them in claims management and overall revenue management for pharmacy billing. Our experienced agents carefully analyze and check the status of the insurance policies with regards to plan exclusions, modifications and other criteria related to a patient’s eligibility process.

MBC’s customized insurance verification covers all steps such as:

• Accessing the details of the patients though secure channels like Fax, FTP, secure email and Practice Management Systems
• Coordinating with the insurance companies for patient’s insurance coverage, verification, co-pay information, demographic information, benefits information, coverage start and end dates, billing system update, member ID, group ID, Pre-certifications and any authorization required in case of any emergencies
• Verifying patient’s coverage on all primary and secondary payers and resolving coverage issue (if any) prior to patient treatment
• Updating the verified results with the practice so that they can discuss the payment options with the patients at the time of their appointment.

Advantages of verification services for pharmacy billing providers:

• Minimize claim denials and payment delays
• Timely reimbursements
• Cost savings of up to 30-40% by reduction in claim rework time
• Cost-effective and quick services
• Expertise in gathering complicated verification requirements
• Insurance verification’s to be complete before the patient’s appointment
• Experts work with patients and payers to verify medical insurance coverage and generate claims for services rendered
• Verification of :
  • Effective date and coverage details
  • Individual patient eligibility
  • Type of plan
  • Payable benefits
  • Co-pay
  • Deductibles
  • Co-insurance
  • Claims mailing address
  • Referrals & pre-authorizations
  • Pre-existing clause
  • Life time maximum
  • Other related information

As a leading global medical billing and coding outsourcing company, we work with advanced technology and deliver on-time, precise and customized insurance eligibility verification for pharmacy services. Being HIPPA compliant, we have timely QA checks in place to provide high quality accurate solutions. Apart from reducing a practitioner’s time and bandwidth spent on insurance verification, we provide value-added services by getting more returns out of their investments.

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Nobody likes to lose money and the same holds true for the pharmacists. If billing your pharmacy is a nightmare, then outsourcing is the answer to it. Outsourcing always seems to be a smart option for your pharmacy billing requirement.

Regardless of whether you keep your billing operations in-house or outsource them, the first thing that should concern you is the best billing and coding practices. The complete effectiveness of your pharmacy billing starts and ends with your billing and coding knowledge.

Let us take a look and some pros and cons of billing your pharmacy in-house:

Pros:

Maintaining control:

Medicare prescription drug plans’ require compliance and laws that apply to the submission of prescription claims under the Medicare Part D program. Substantial practices and medical groups often opt for an in-house pharmacy, which is regulated on a state-by-state basis. Hence, the in-house billing team must be certified, trained and experienced who can expertly handle various categories of drug codes.

ROI- Return on Investment:

The efficient management of Pharmacy Billing provides opportunities to improve efficiency in handling patients and improve the bottom line of businesses. Once you have invested in training pharmacy billers and purchasing billing technology, means losing lots of time and money spent. When there’s a valid infrastructure in place, it’s worthwhile to just refine existing processes to generate the best ROI.

Cons:

Billing liabilities:

The U.S. Department of Commerce estimates that $500 billion is lost to internal business theft every year. The pharmacy billing departments can go largely unnoticed if the managers don’t keep a stringent eye on the billing operations

Support Issues:

If your billing department comprises of only two or three staffers, your operations – and cash flow – can be majorly obstructed when even just one employee gets sick, goes on vacation, takes a leave of absence or quits altogether.

If you really want to know what you are getting yourself into, get immediate access to a dedicated team of billers and coders, where you can be assured accurate, smart and seamless billing service. Once you entrust your pharmacy billing process to an outsourcing medical billing firm, they will take care of the entire revenue cycle spanning across the following area:

• Pre-admission procedures
• Data entry of patient information during admission
• Coding of data
• Billing statements generation
• Accounts receivables management
• Interactions with insurance companies including claims follow up, approvals and denials
• Hospital billing collection services
• Collections reporting

Moreover, the team constantly works on updating the knowledge about the new regulations and developments in the pharmacy and healthcare industry.

What are your benefits by outsourcing pharmacy billing?

Apart from releasing your distress from the managerial and infrastructural hassles of maintaining an in-house pharmacy billing division, outsourcing can guarantee:

• Timely billing of accounts
• Real-time generation of billing status reports
• Structured processes and quality control measures to ensure error-free billing
• Increased collection ratio with a faster collection of accounts receivables (AR)
• Increased reimbursements by over 20%
• 60% savings on your operating costs

That is not all; they can take away the entire administrative burden off your shoulders so that you can forget tedious stuff and concentrate on serving your patients better.

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