7 Tips to Ensure Success in Pharmacy Billing with Altering Healthcare



It is difficult to sustain in a constantly altering healthcare industry and avoid losses.With the ever-changing healthcare industry and a rapidly growing relationship between physicians and pharmacists that is creating an influx of patients for both the professionals, pharmacists are becoming busier by the day; as more and more patients are taking help from pharmacists in not only asking prescription related queries, but also inquiring and interacting with them on diet/lifestyle changes.

Hence, pharmacists today need to focus on the foremost and toughest things which is accounting and bookkeeping. Here are some tips that can ensure success in pharmacy billing:

1. NCPDP sign up: Pharmacists must sign up with the database service of National Council for Prescription Drug Programs (NCPDP) which permits a pharmacy to bill. A six-digit number is provided to all pharmacies, known as the BIN, which is used for identification.

2. Insurance billing: Pharmacists must keep a 3rd party cheat sheet book. This should have a list of pharmacists who can be of help when required; should contain the state Medicaid’s BIN number; and must contain the billing procedure of test strips for Medicare Part B etc.).

3. Third Party Relationships and contracts: Insurance agencies have a third party known as the Pharmacy Benefit Manager (PBM), e.g. Medco and Express Scripts. These perform the complete auditing and verification of the prescription billed for the insurance company.

Also, signing contracts is imperative. A pharmacy cannot bill to PBM unless a contract has been signed (by the third party) as this contract allocates the co-pays etc. to the pharmacy. Apply for insurance contracts (associate with local pharmacy groups and then with contracts via that group) and start billing with the complete details of the prescription and the patient’s demographics.

4. Technology: Pharmacists must use the latest pharmacy billing software – QS1. And must always verify in case of doubt (e.g. if a certain drug is reimbursable or not) with the insurance agency. The latest technology ensures a smooth and flawless billing process.

5. Financials: For financial reliability, ensure that the co-pay and amount reimbursed by the insurance agency are equal to the amount billed. Make certain that patients are aware of the cost of services, and that they are responsible for its payment if the insurance payer does not reimburse. Maintain a document of each patient and the services provided.

6. Web claims: For web claims, pharmacists must ensure they have a personal identification number (PIN) from Division of Medical Assistance Programs (DMAP) for Medicaid services. Web claims must not be submitted if hard copies need to be attached, or claims are being filed more than a year after the date of service.

7. NPI number and codes: Obtain a National Provider Identifier number. This is especially useful if the billing for clinical services by pharmacists has to be done via a physician’s office. Pharmacists needs to be aware of CPT codes which are specific to MTM (Medication Therapy Management) services provided by them (Medicare Part D payers compensate MTM services for entitled patients).

Create a standard process for all patients for delivering utmost care and wellness eventually leading to a resourceful practice and hence succeeding in a competitive environment. Thus, with a smooth pharmacy billing process in place, there will be higher reimbursements and more profits.

This entry was posted in Medical Billing, Pharmacy, Pharmacy Billing Services, Practice Administration, Revenue Cycle Management (RCM). Bookmark the permalink.


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