Today Pharmacists have transformed their practice from just being dispensers of medicines over the counter to providers of healthcare. They are increasingly providing direct patient care based on a scope that is directed in the states in which they practice in a variety of settings right from inpatient, outpatient, and community pharmacies. The most accessible are the Community pharmacists with 93 percent of Americans living within 5 miles of a community pharmacy.
In the community pharmacy setting, pharmacists, depending on the state’s regulations, can establish a direct billing mechanism for patients (cash transaction), provide services under a third-party insurance-contracted service, or use pharmacist-specific MTM Current Procedural Terminology (CPT) codes. There are other ways to reimbursement such as “incident-to” billing and outpatient facility-based billing, largely limited to pharmacists practicing in an ambulatory care clinic or hospital outpatient clinic, respectively. Alternatively, through negotiating contracts with different payers or self-insured employers, pharmacists can improve their billing.
The new delivery models based on the value based care are now seeing ways in which pharmacists can improve their Revenue Cycle Management System.
So given the number of opportunities that pharmacists now have at their disposal to increase their revenues, how can they improve the billing process that will not lead to denials and rejections?
Automation: Pharmacists need to automate their systems. This not only helps prevent abuse and fraud especially when disbursing medications via refills, but also helps save them and the technical staff time to help be the “providers” of medication and healthcare they have now been endowed with. Huge investments are not required for automation or on a large scale. Automating repetitive jobs that a machine can handle rather than have a staff handle it, will be a time saving effort.
Workflows: Re-engineering the workflow, evaluating staffing needs and incorporating technology can help in the medication synchronization programs that many pharmacists have initiated. Bring in experts to know how your pharmacy can meet the challenges of the times. Whether as pharmacist you handle inpatient, outpatient or community – revenue is what will drive the upgrades and staffing to handle the increased inflow of patients. Organizing teams to handle different workflows and coordinating them for a seamless process, with knowledge of the pain points and minimizing them helps make serving the community a pleasure.
Coding Rules: For a successful and effective pharmacy billing, efficiency in coding is of paramount importance. Pharmacists have been using CPT codes for seeking reimbursement thus far for interventions such as reviewing a patient’s history, creating a medication profile for a patient, and making recommendations to a patient for improving compliance with therapy. They have also been employing the JW modifier, and here need to be very careful as the JW modifier is not used on claims for drugs or biological provided under the Competitive Acquisition Program (CAP). They need to know the rules and regulations and check with their respective state Medicare Contractors before applying modifier JW. So outsourcing your pharmacy coding and billing practice would help you concentrate on delivering the services and still maintain your increasing revenue streams. But simultaneously keep updating your checklist of codes, so that you are in sync with the experts and staff can keep an eye in case of errors
Documentation: This helps avoid fraud and abuse. Potential fraud exists because the pharmacy may receive reimbursement to which it was not entitled. Implementing a pragmatic partial-fill protocol, including proper documentation, to avoid accusations of partially filling prescriptions in an effort to generate dispensing fee revenue is very necessary. Regular short internal audits introduced will go a long way in helping the billing process flow smoothly. By introducing reward competitions among the staff for the perfect documentation and keen eyesight to catch errors, can make your documentation more robust and help build a more productive workforce.
Ensure collaborative protocols: most collaborative protocols between a physician and a pharmacist are narrow in scope, limiting pharmacist clinical services to specified patients and disease states. Thus each setting needs to refer to the specific rules in the state in which the pharmacist will practice to determine the extent to which clinical pharmacy services can be provided under protocol.
Payments for pharmacy services provided through state Medicaid programs vary from state to state. The most commonly reimbursed services in the 15 states that provide Medicaid compensation for direct patient care include smoking cessation, counseling, and other preventive services. So knowing the CMS rules & regulations, and what covers the ambit of patient care that you can request for reimbursement can be very taxing. Engage with experts to help you navigate these protocols and rules for improved billing systems.
Innovation does not mean bringing in advanced technology. But innovative approaches towards the challenges faced, be they tiny innovations among staff, or even in the workflow, after studying the gaps and conducting minor audits, will help any pharmacy provide better healthcare towards their community participants.