Pharmacy Billing for Long term Care Facilities: Challenges and Solutions

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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.n

What is a Long-Term Care Pharmacy?

nLong-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.n

Pharmacy Services and Their Types



nThis 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.n

Home care

nThis 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.n

Managed care

nThis 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.n


nThis 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.n

Challenges of Pharmacy Billing

nHere are few challenges of pharmacy billing;n

Lack of Experienced Billers:

nAnother 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.n

The Audit Specter:

nWhen 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.n

Improving Accuracy:

nFilling 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.n

A/R is Getting Older:

nA/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.nnAlso Read:n



nHere are few solutions of challenges in Pharmacy billing;n

Prescription Refills:

nNew 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.n

Pharmacy Billing:

nWe 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.n

How Does an LTC Pharmacy Handle Their Billing?

nThe 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.n

Preventing Pharmacist Errors

nPharmacists 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.nnThe 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.n

Incorrect Payment Posting in Pharmacy Billing

nPharmacies 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.nnYour 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.n


nThe 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.

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