pharmacy billing

From pharmacy to patient’s hand, prescriptions undergo many stages of reimbursement. Filling a prescription and adjudicating it may seem complicated, but it is the only way to understand pharmacy billing. 

If you are a physician and thinking about offering medications through your own office along with your healthcare services, it is an option worth considering. It can contribute to your practice revenue while providing an added convenience to your patients.

As you are aware, the health care industry is a complex one that is constantly changing and evolving. That is why it is so crucial to understand all the requirements and coding a medication department needs to implement it properly in your practice. 

According to a Drug Trend report, pharmacy reimbursements are affected because of continuous changes in the prices of biotech and traditional drugs. And, now average sales price has decreased from 6% to 4% on non-pass by CMS. This shows how tricky managing billing and reimbursements can be in the pharmacy industry.

So, here are seven important facts about pharmacy billing and reimbursement that you need to know before implementing medication services in your practice. 

• Keep Aware of the Changes in the Drug Prices

Like any product, there are changes in the prices of drugs. Hospitals are buying drugs at higher prices as compared to fixed-fee payers. There are opportunities to buy drugs at lower prices, but other alternatives are not searched properly. It is important to have a process to find out the prices and compare the spending with reimbursements. 

• Understanding the Coding

Drugs have to be coded correctly for getting reimbursements without a hassle. There are HSCPS codes, and you have to do them appropriately. Otherwise, if a patient is not billed correctly, the reimbursement will not be obtained accurately. And the healthcare provider will face denials which may lead to losses of thousands of dollars. 

• Managing the Work Flow

It is critical to understand the workflow in pharmacy billing and reimbursements. Buying the drugs, procuring them, accurately coding, and finally getting a reimbursement. Ideally, a physician gives a prescription, and then a pharmacy gives the medicine to the patient.

But this process is more complex than it sounds; all the information must be entered correctly to accurately billing the patient and avoid getting denials from healthcare insurance companies.

To manage the workflow correctly, you need to have a plan with you. Everything has to be planned, from buying the wholesaler to delivering the claim to the patient or healthcare insurance company.

• Rules and Regulations in Pharmacy

It is critical to be knowledgeable about the rules, compliances, and regulations in pharmacy. It is recommended that your coding is done appropriately according to the Current Procedural Terminology (CPT) codes for pharmacists who are practicing Medication Therapy Management (MTM).

Following these rules and regulations is important to have a correct reimbursement and avoid getting yourself into any trouble because these are strictly followed by everyone related to the healthcare industry.

Similarly, the rules and regulations will vary according to the healthcare field. It is best to know about all the procedures and rules to avoid any pharmacy billing and reimbursements.

• Procurement Stage

The drugs are transferred to inventory and unit of measure (UOM) from the pricing and quantities at the procurement stage. When the medicines are delivered from the wholesale provider to the pharmacy, all the data is entered into the system. 

All the data is checked manually to avoid any errors or mistakes. This is an initial stage, any errors in procurement can lead to further issues in the next stages. Having an experienced and professional staff is vital to procure medicines accurately.

• Avoid Errors in the Charge Master

The chargemaster has the information regarding the billing of the medicines. A pharmacist has to make sure the right quantity is entered into the system. You have to take care of the units of measure, the prices, and the coding to do the right billing.

Furthermore, miscoding and omission of a medicine can lead to many problems like late or low reimbursements and denied claims.

• Keep in Check with the State Laws

You have to make sure what state laws allow you to do. In most states, pharmacists are allowed to make changes in the prescription, so they are given independence at certain levels depending upon the state laws. 

Similarly, if you plan to incorporate the pharmacy department in your practice, you have to make sure if your state will allow it. And what regulations and rules they have for doing a pharmacy business.

Still Not Sure How You Can Improve Your Pharmacy Billing?

MED-Miles can help you with pharmacy billing and reimbursements. We have experts who have been providing pharmacy billing services for almost a decade now. They have experience working for many healthcare providers who have an accurate billing system now, facing fewer denials and getting reimbursements at the right time. Contact us at +1 888-598-9181.