March 10, 2016
Pharmacy billing entails the payment for services when qualified pharmacists perform all functions within their scope of practice as permitted by state law, thus allowing reimbursement for pharmacists to manage drug therapy within a CPA (Collaborative Practice Agreement). Some state laws allow practitioners to establish CPAs in all practice environments, while others restrict CPA utilization within an institution. It is noteworthy to remember, each state has different regulations dictating the roles and responsibilities in which a pharmacist may engage. Hence before engaging with a pharmacist, please ensure that all regulations have been complied with, else this may affect the Revenue Cycle Management (RCM) process, and your billing could take a financial loss.
Against this background, healthcare providers need to ensure billing is efficiently done when the pharmacy is involved. It is a known fact that many hospital pharmacies are not able to actively improve revenue integrity due to lack of resources, limited time and service demands. The efficiency of this department is highly critical, as they are dealing with medications and solutions to the patients' health-related problems.
Ensure efficient patient process:
Streamline prior authorization form generation with all supporting documentation, especially for cognitive services. When errors occur at critical points in the flow of data, inaccurate reimbursement is inevitable.
Documentation that demonstrates pharmacist clinical services' benefits and prospective cost savings to current and potential payers should be secured. Ensure that regular comparison of drug spending to reimbursement is conducted, as very often hospitals may buy drugs at a higher price than they are being paid by fixed-fee-based payers. Proper and efficient use of Bar Code Medication Administration should be ensured for accurate billing.
There is a need to ensure that reimbursable medications are not found missing from or miscoded in the charge master, and due diligence should be paid to even something as tiny as a typographical error in a dispensing cabinet, or entering an incorrect billing unit of measure (UOM). Hence, better to avoid employing the manual processes for updating even the price of items in the charge master. The dosage quantities required for patient use are often quite different from the quantities purchased. Data exchange between pharmacy and patient-focused clinical systems involves converting drug inventory data on quantities purchased to the quantity-levels required for administration to the patient.
Price updates -
Average wholesale price (AWP), average sales price (ASP) etc. for medications should be checked at least every quarter, and updated in the pharmacy and or/hospital billing software (As drug prices increased, CMS on the other hand, reduced its average sales price (ASP) margin from 6 percent to 4 percent for non– pass-through and raised the threshold for separate reimbursement to $65)
Regular review of Centers for Medicare and Medicaid Services (CMS) coding of medications for reimbursement should be followed up regularly where billing codes are implemented for new medications – like maintaining J code & other billing code accuracy.
Employ an expert:
To avoid financial loss in reimbursements, an expert with extensive knowledge of disease-specific drug therapies and manage care plans should be part of the billing team.
Monitoring medication reimbursement changes from private and government payers and ensuring updating of hospital billing and coding procedures. Procedural breakdowns such as coding errors and failure to charge for medications may go unnoticed for weeks. Develop systems for account receivable reconciliation to monitor pharmacy net margins.
Take the pro-active approach and invest in new technology and automated processes to improve financial performance.
Best Billing and Coding Practices