Efficient ways to Track Claims Reimbursements for Pharmacy


A critical function of any healthcare provider, including pharmacy, is the Accounts Receivable segment. Failure at this node can lead to the loss of much revenue. To achieve optimal organizational performance every business has to create a balance of people, processes and technology to support them leading to a workable environment. It is a known fact that many pharmacies, independent or attached to hospitals, may not have the resources to track third party reimbursements, especially at the claim level. The result of unpaid claims and loss of reimbursement checks from third party payers can bring financial harm to the Revenue Cycle Management (RCM) process.

A proactive approach to better documentation in terms of billing and coding and enhanced financial management can make a marked change in the RCM process. In today’s world of new technologies, vigilant auditors, demand for a more effective and efficient method coupled with compliant and legitimate pharmacy reimbursement practices are now being sought.

In order to make claim reimbursements effective, the whole process of pharmacy billing from the start needs to be enhanced. Simple yet effective ways can be put into place for pharmacies to help track claims.

  • Provide for a more Responsive Help desk.
  • Enable electronic verification of reimbursement against contracts.
  • Communication channels should be more proactive when chasing details during verification and eligibility.
  • Submission of claims should be rechecked especially for Medicare reimbursements.
  • Ensure alert, experienced and knowledgeable managers who are updated about current AWP increasing profits and Point-of-sale alerts when U & C pricing is below the Medicare/Medicaid allowable price point.
  • Provide for automatic submission of dispensing and supply fees for eligible products. Address the gap between the purchase price and the patient charge.
  • Eliminate manual input and processing errors, especially when maintaining the charge master. This helps avoid missing or miscoded data in the charge master. Determine volume reconciliation capability to ensure correct coding and thus ensure charges are paid. Do not rely entirely on automated dispensing devices, as they do not check for correct coding, instead learn to capture the charge upon administration in dispensing devices.
  • Overcome fraud liability by engaging with technology to help maintain a modernized drug billing system which should be designed to avoid billing errors.
  •  Establish regular internal audits and fiscal reviews. Profit from employing an effective audit management tool that combines pharmacy claims auditing with innovative data to help predict patterns that can identify potential recovery from pharmacy claims.

A streamlined process integrated with the right technology and know-how, in-house or outsourced, with regular monitoring and auditing can effectively help track pharmacy claims, increasing profitability and financial output.