Read our latest pharmacy billing services blog
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Pharmacy Billing Services
Understanding Prescription Insurance Claim Process
After submitting a claim from the pharmacy, it will then hit a service that routes the claims to the proper insurance company or PBM based on the identifiers. These are known as ‘switches’; examples of companies that offer switching services include RelayHealth and Emdeon. Switches usually charge a fee for every transaction, although they might also charge a flat monthly rate. Of note, this price is independent of insurance payment, so if an insurance company…
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Pharmacy Billing Services
Pharmacy Claims and Commercial Payers
The most common categories of commercial payers to be aware of are employer-sponsored health plans and manufacturer vouchers. In the case of the patient with commercial coverage, by law, it is billed before Medicaid and Tricare and is almost always the primary payer. A common misunderstanding among patients with manufacturer vouchers (i.e. ‘co-pay cards’) is that if their primary insurance does not cover the medication that it can be run through the voucher for the…
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Pharmacy Billing Services
Maximizing Reimbursement and Minimizing Liability by Using Pharmacy Audit
Payers audit pharmacies because of billing history, a referral from an FWA hotline, a routine, random audit, or other reasons that might signify a potential for FWA to the payer. Often it is in the form of a desk audit, where the pharmacy will be required to fax documentation back to the payer, but can also be an on-site audit. During an on-site audit, the auditor might ask for a lot of different documentation and…
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Pharmacy Billing Services
Barriers to Ambulatory Care Pharmacy
Basics Ambulatory care pharmacy practice is the provision of integrated, accessible health care services by pharmacists who are accountable for addressing medication needs, developing sustained partnerships with patients, and practicing in the context of family and community. It involves being an integral part of an outpatient, multidisciplinary healthcare team to improve quality and patient outcomes by focusing on medication management. When ambulatory care pharmacists engage inpatient care to their full capacity, physician time is saved,…
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Pharmacy Billing Services
Developing Fee Structure for Pharmacists
In the absence of any outside contracts with MCOs, all payers for service must be charged the same fee. This means that cash-paying customers must be charged the same fee that is billed to third-party payers. To charge the insurance companies a rate higher than the cash-paying customer may be considered fraud. It is important, therefore, to ensure that the fee structure is well defined and designed to cover direct and indirect costs associated with…
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