pharmacy billing

Pharmacy billing is the profession’s greatest challenge and opportunity this decade and will not be successful without the strong support of pharmacy technicians. Focusing on patient care delivery and health insurance billing in outpatient and community pharmacies requires a fundamental shift in systems and workflows. Technicians play a role in driving the integration of services into the pharmacy workflow and are at the forefront of the pharmacy process.

What is a Long-Term Care Pharmacy?

Long-term care (LTC) pharmacies serve residents of nursing homes, assisted care facilities, extended care facilities, and/or retirement homes. These are usually “closed” pharmacies, meaning that someone cannot walk in and get a prescription filled like at a community retail pharmacy.

Pharmacy Services and Their Types

Clinical

This type of service includes an integrated payment module. It’s essential to handle paperwork, all of which is non-clinical. With this type of billing, you need to be careful about the paper test.

Home care

This type of service involves delivering injectables to patients from home. These services are enclosed by Medicare Prescription Drug Improvement and Modernization (MPDIM). It requires data processing which may not be an integral part of your core competency.

Managed care

This service is similar to clinical services and is provided by large hospitals and nursing homes that realise their reimbursement through a combined payment model. It means heavy non-clinical paperwork and constant report generation.

Radio

This is an important adjuvant therapy service and is covered by the Medicare Prescription Drug Improvement and Modernization Act (MPDIM). It requires intensive professional help with accounting and coding.

Challenges of Pharmacy Billing

Here are few challenges of pharmacy billing;

Lack of Experienced Billers:

Another problem pharmacies face is attrition, which is why they have to make do with less experienced billers. And the cost of doing so is often very high. With inexperienced billers, you have to deal with issues like incorrect coding, incorrect billing calculations, incorrect modifier usage, incorrect primary payer billing, etc. Some pharmacies believe they can overcome this by having a good quality control team. But even the quality control team is prone to error because they are often forced to bite off more than they can chew.

The Audit Specter:

When there are too many errors, the auditor will be knocking on your door. And whether it’s Medicare or other payers, when they come knocking, they’ll leave no stone unturned to uncover flaws in your process. If it is implemented, you will have to face consequences that can range from heavy fines to cancellation of contracts with the payer. So, if you want to keep the auditor at bay, it’s important to have proper control over your process. If not, you may have to conduct regular internal audits with the help of third-party agencies, which is again too costly.

Improving Accuracy:

Filling high-volume prescriptions can turn your pharmacy into a three-ring circus. If your pharmacy serves a long-term care facility, you know that filling high-volume prescriptions on schedule requires fast and clean order processing. Each regulation requires careful monitoring of policies, procedures, and detailed regulations. If you’re managing growth, adding new long-term care (LTC) homes, or acquiring another pharmacy, your challenge is even greater.

A/R is Getting Older:

A/R aging is a common problem faced by pharmacies. It is the most common in all infusion pharmacies. This means that when the oldest accounts exceed 90 days, they enter the realm of write-offs. And when you have more of them, you’re staring down the barrel. And to make matters worse, there are no appropriate means and strategies to deal with it. Therefore, when your high-dollar A/R needs focused attention, you don’t have enough resources to implement a strategy to collect delinquent accounts.

Also Read:

• Pharmacy Billing & Reimbursemet
• Affordable Care Act on Pharmacy Billing

Solutions 

Here are few solutions of challenges in Pharmacy billing;

Prescription Refills:

New or supplemental orders, whether received electronically or by fax, are processed one at a time as directed by the pharmacy. Denied claims, early refills, duplicate documents, and cycle medications are properly processed by the team to ensure patients receive all needed medications on time. They can also work overnight to help the pharmacy get the maximum number of refills on morning drives.

Pharmacy Billing:

We will work side-by-side with your billing team to help you manage daily workloads including income registration, insurance eligibility, prior authorization, census maintenance, payment posting, and pending Medicaid status checks.

How Does an LTC Pharmacy Handle Their Billing?

The LTC pharmacy may bill nursing home residents/facilities on a pre-consumption basis. This means that the resident and their insurance company (or in some cases the facility for home stock items) are billed for the medications before they are issued to the facility. This is usually the same as how the community/chain/supermarket/independent retail pharmacy receives bills. The retail pharmacy charges are based on preliminary consumption. The patient pays for the medication before consuming it.

Preventing Pharmacist Errors

Pharmacists tend to rely too much on technology. With a more personal approach and manual review of each prescription to ensure the request matches the final product, pharmacists can catch last-minute errors.

The problem is the workload, which leads to stress and fatigue. Pharmacists should hire more staff to help ease the burden and give pharmacists more time to fill each prescription. Validating unclear information is also important.

Incorrect Payment Posting in Pharmacy Billing

Pharmacies often have to deal with misbilling outages, especially when they are short-staffed. As a result, this leads to an incorrect A/R calculation. This again leads to loss of income and affects the inflow of income. Without a proper payment posting process, issues keep recurring and some of these recurrences may even lead to rejection.

Your success with outsourcing depends largely on the type of provider you choose. Of course, experience matters most. Always look for a provider that has equal expertise in both pharmacy and medical billing. But along with that, you need to look for suppliers who won’t give you any variable costs, hidden fees, and more. By ensuring this, you ensure that you get value for the money invested.

Conclusion

The roles of technicians continue to expand. They can handle administrative challenges with their attention to detail, deep understanding of pharmacy practices and workflows, and strong technical skills, making them ideal candidates to advance medical billing and pharmacy services.

 In developing the ACA, lawmakers were tasked with providing consumers with affordable drugs. Without restricting the pharmaceutical market or limiting medical progress. Instead of addressing the actual costs or cost structure of drugs, the ACA focused on improving access to health care plans. Thus, the total burden of prescription costs fell on federal programs and insurance companies. The ACA also sought to increase drug rebates to reduce costs.

Goals of Affordable Care Act

The Patient Protection and Affordable Care Act, referred to as the Affordable Care Act or “ACA” for short, is a comprehensive health care reform law enacted in March 2010.

The law has 3 main objectives:

• Make affordable health insurance obtainable to more people. The law provides subsidies to consumers (premium tax credits) that reduce costs for households with incomes between 100% and 400% of the federal poverty level (FPL).
• Expand Medicaid to cover all adults with incomes below 138% of the FPL.
• Promote innovative methods of providing medical care to reduce overall healthcare costs.

Essentials Health Benefits

• Emergency services
• Hospitalisation (surgery and inpatient care)
• Laboratory services
• Services related to mental health and substance use disorders (including behavioural health care such as counselling and psychotherapy)
• Ambulant care
• Pregnancy, maternity, and newborn services (includes prenatal, delivery, and postnatal care)
• Prescription drugs
• Preventive care, wellness services, and chronic disease management
• Rehabilitation and habilitation services and facilities (to help people gain or restore skills after injury, as well as amid disability or chronic conditions).

What has Not Covered the ACA Benefits

Basic health benefits do not include some services, such as:

• Dental coverage for adults, although some plans may offer this as a benefit
• Vision coverage for adults, although some plans may offer this as a benefit
• Long-term care service
• Vasectomy.

Impacts of Affordable Care Act on Pharmacy Billing

Here are;

Payments for Medications:

One area the Affordable Care Act addressed was determining how Medicare reimburses all pharmacies for selling generic drugs. Before the legislation, the amount of reimbursement offered to pharmacies was often lower than their actual acquisition costs. The impact of this change will improve the annual Medicare payments that pharmacies receive from the government. The amendment also expanded the number of covered entities eligible for drug rebates under the 340B program. However, the discount does not register with hospital patients. The new guidelines help covered entities enter into new contracts with more pharmacies that use their services.

DME Accreditation Regulations:

Some pharmacies that offer durable medical equipment (DME) through Medicare may not meet accreditation requirements. This exception does not apply to those pharmacies that want to participate in the tender process. The criteria for obtaining an exemption from DME accreditation include many provisions. This exemption only applies to pharmacies that have been enrolled in Medicare for at least five years.

DME billing must be five percent or less of the pharmacy’s prescription sales. Pharmacies must have an absence of allegations of adverse fraud and abuse within the past five years. The DME billing percentage is determined based on a three-year average of all billings. And must be less than five percent of the pharmacy’s sales. Each pharmacy is also required to submit all documentation to verify its eligibility before an exemption is granted.

Rise of High Deductible Health Plans:

Payers have begun raising their premiums to compensate for the challenges associated with the health insurance exchange environment. In response, patients try to choose plans that offer the lowest possible monthly premiums. Even if those reduced costs are offset by higher out-of-pocket deductibles that must be paid when they receive care.

Improve Health Quality and Curb Costs:

The ACA requested investments in health information technology. It addressed guidelines to reduce medical errors and create payment mechanisms to improve efficiency and results and improve care coordination among providers. The act requires oversight of health insurance premiums and practices, reducing health care fraud and uncompensated care to foster comparison shopping in insurance exchanges to increase competition and price transparency.

Reducing Medications Waste in Pharmacies:

The Affordable Care Act requires Medicare Part D enrollees to become more involved in dispensing drugs to patients while reducing drug waste. This plan was created in 2012 and all healthcare facilities are required to look at how they dispense drugs to Part D enrollees. Everyone in the industry is trying to reduce the number of drugs that are wasted every day. The risk of this new effort is that pharmacies will have to dispense drugs more often. To offset the increase, it is not necessary to add the increased dispensing fee to the fees.

How this law will affect pharmacies in the future is unclear. No one in the industry can predict how the implementation of regulations will change. The federal government must provide some guidance on healthcare issues that concern pharmacies.

Also Read:

• Pharmacy billing and reimbursement

Pros and Cons of Affordable Care Act 

Pros;

• It expands the availability of health care for more citizens.
• Prevents insurance companies from disproportionately raising rates.
• Individuals with pre-existing medical conditions cannot be denied.
• Coverage of additional screenings, immunizations, and preventive care.

Cons;

• Those who were already insured saw their premiums increase.
• The taxes were created to help supplement the ACA, including taxes on medical equipment and drug sales.
• Registration time is limited for new applicants.
• Many businesses have reduced employees’ working hours to avoid providing health insurance.

Recommendations for the Future

The ACA did not introduce systemic changes to the actual cost of prescription drugs.

One of the key reasons was the fear that it could hinder the development of new drugs. Pharmaceutical companies continued to develop new, life-saving drugs. However, they are now some of the most expensive drugs available. So, the question of affordability remains.

• Improving access and affordability: Reducing out-of-pocket drug spending.
• Addressing high drug prices: Eliminate incentive programs that encourage doctors to prescribe higher-priced drugs over more affordable ones.
• Advice on evaluating drug prices: Analyse cost-effectiveness and determine coverage and reimbursement strategies.

Conclusion

The Affordable Care Act increased the number of people covered by insurance and helped lower healthcare costs. Its continued implementation is needed to make further progress. By making health insurance more accessible and affordable, increasing coverage, funding, and support for community-based public health and prevention programs, and tracking key health measures, the ACA begins to reduce health insurance disparities, increase access to preventive care, improve outcomes in health and reduce the rate of growth of national health expenditure.