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How To Find The Right Pharmacy Billing for your Practice

May 06, 2016

pharmacy practices billing

Pharmacy billing can be a daunting task, be it at a hospital or for your private practice. There are seven basic steps for pharmacy billing:

  1.       Intake registration & Insurance verification eligibility
  2.       Prior Authorization- coverage of medicines
  3.       Census Maintenance
  4.       Medical coding
  5.       Payment Posting
  6.       Accounts Receivable Management
  7.       Medicaid Pending Status check/ Claims denials

Billing is an art, when it comes to medical billing and coding. Pharmacies worldwide are moving towards automated systems. However, there is still a miniscule amount of manual entry that is present. And a single error can be costly and cause havoc with the Revenue Cycle Management (RCM) Process. If this appears daunting to handle within your own organization, especially with respect to the new healthcare reforms and the constantly changing rules &regulations, then outsourcing the specialized billing part is the solution. However, who do you think can be the one that can handle your systems? If customization is required, will they handle it well, especially if you cater to specialty/specialties? Of the above mentioned cycle, you need to find whether you should outsource part or the whole process? Research your weak points and then look for who can handle just part of it or the whole pharmacy billing process, but with regular monitoring. So what do you need to look for when outsourcing pharmacy billing? How can you whet them? Here we have  prepared  a simple checklist that can help get you started if on the lookout

Proper Documentation: If knowledge and experience is present in terms of proper documentation and guidelines, awareness and experienced with updated rules and regulations, and more specifically have the knowledge of different drug categories where prior authorization is required, then you can safely know that your Revenue Cycle Management processes will be streamlined well. How well trained are their staff in the admissions and verification & eligibility process, is also a check point that you need to consider as it’s a very crucial and sensitive process

Fewer claims rejections: Account Receivable Management systems need to be streamlined & well aligned. Knowledge of branded and non-branded drugs and generic drugs should be present so as to code and bill as per the rules. Check out their past history and rate of claim denials and rejections, has it decreased over the years? If yes, then this will definitely help increase your revenues and bring in quality billing to your pharmacy

Compliance: Are they HIPAA complaint? Do they have they necessary compliances to bill for branded drug categories? Do they follow compliance audits which can help eliminate errors? Many Insurers perform Drug Utilization Reviews and call in for authorization checks, which can overwhelm an untrained staff. Background checks on this will give you answers

Thus, at the end of it, if you feel by outsourcing you are relieved from the managerial and infrastructural hassles of maintaining an in-house pharmacy billing division, then go for the whole or part package depending on the terms and conditions of the outsourced vendor.

A simple checkout:

  • Transparent and strong relationships with healthcare professionals
  • Display Reduced management costs of who they are currently servicing
  • Display Data-driven and faster decision making
  • Present Stringent quality programs
  • Greater accountability and transparent reporting

This will go a long way in helping you pick up the best and know that you have banked on the right pharmacy billing vendor for your practice.


Category : Best Billing and Coding Practices