Pharmacy Billing Facts you Need to Know

Learn important details about Pharmacy Billing Facts to enhance your understanding of healthcare revenues, ensuring effective management of billing and coding processes and revenue success. It encompasses a huge array of facts to understand before billing. Like all other specialties, pharmacy comes with its own set of problems associated with reimbursement and profitability. To add to the existing woes, reimbursement requires handling of data at multiple levels along with a constant follow-up in most cases, posing challenges. Although pharmacy claims are distinct from those of a hospital, they are still subjected to HIPPA rules.

Gain valuable knowledge about Pharmacy Billing and Coding Facts that are crucial for effective revenue management in this sector. Understanding key aspects such as coding accuracy and reimbursement processes is essential for a successful and streamlined billing approach.

Essential Pharmacy Billing Facts You Must Be Aware Of

  • The first step is signing up with the NCPDP, a service that allows Pharmacies to bill. A unique number is provided by the NCPDP to each pharmacy that it identifies for billing.
  • Every insurance company has a third party- a Pharmacy Benefit Manager (PBM). These intermediaries are billed on filing a prescription and they audit to ensure everything is appropriate.
  • Signing a contract is an essential part however, you must understand and read through well before signing any such contracts. Realizing allowable and payable charges is important for a successful billing cycle.
  • A pharmacy will not be able to bill a PBM unless it has signed a contract that entitles the payment to be paid to the pharmacy, co-pays, etc. Every PBM has different contracts.
  • Technology is an inevitable part and for pharmacies too, billing is made through billing software such as QS1. Most of the processes are automated in the billing process, however, there may be some cases needing prior approval and specific billing. For these, it is necessary to verify with an insurance company if the drug is reimbursable.
  • On receiving a prescription from the community pharmacy, it is important to note the source of the prescription to understand if it is for a Medicaid or Medicare patient. This is tracked using origin codes which are as below-

0- Unknown is used when how the original prescription was received is not known, which may be the case in a transferred prescription.

1- Prescribed paper, which comprises computer-printed prescriptions that a physician signs as well as traditional prescription forms.

2- Telephone prescription obtained through oral instruction or interactive voice response.

3- E-prescriptions transferred from a computer to the pharmacy.

4- Facsimile prescription obtained through fax transmission, including an e-Fax where a scanned image is sent to the pharmacy, and displayed on a screen.

It can get simpler once all facts are known and desired methodologies are adopted for a smooth billing cycle. This eventually impacts the bottom line of the Pharmacy, ensuring faster and better reimbursements. MedicalBillersandCoders (MBC) is a leading medical billing company providing complete revenue cycle management services. To learn more about complete pharmacy billing and coding services, contact us at 888-357-3226