How Can Independent Pharmacies Deal With Underpayments?

Have you ever stopped to think about how much your independent pharmacies are earning when it dispenses your medication? It turns out that pharmacies, particularly independent pharmacies, sometimes wind up losing money on those prescriptions.

That’s largely due to the low insurance reimbursement rates middlemen, known as pharmacy benefit managers, or PBMs, pay pharmacies and the fees they charge to pharmacies after drugs are dispensed.

Independent pharmacies are more than 75% of which are located in population centers of 50,000 or less, have been on the decline and represent about 38% of the total retail pharmacy marketplace in USA. The fees/payments are charged on the pharmacies on those drugs covered under Medicare, known as direct and indirect remuneration DIR fees, save the health care system considerable money.

Direct and Indirect Remuneration is a form of performance-based payment used by pharmacy benefit managers to promote value and quality and helps kept premiums down for Medicare beneficiaries. The price concessions that PBMs negotiate with drug manufacturers and drugstores and report to the Centers for Medicare & Medicaid Services as DIR are generating significant savings for the federal government and are projected to save enrollees in standalone

New Reforms Making Pricing More Transparent

When it comes to reimbursements for generic prescription drugs, it may often seem like there’s little rhyme or reason to what is paid. This is unfortunately the case for many independent pharmacies dealing with Pharmacy Benefit Managers.

PBMs, the third party entities that oversee the administrative side of Medicare’s Part D plans, often reimburse independent pharmacies well below their cost in acquiring and dispensing generic prescription drugs.

Considering generic prescription drugs account for 80% of drugs dispensed, underpayments can be a considerable blow to a pharmacy’s bottom line. In an effort to hold PBMs accountable, Ohio Governor John Kasich recently signed into law a bill with amendments regulating how and when PBMs assign drug pricing.

Developing Responsive Solutions

Pharmacy billing programs enable pharmacies to benefit from streamlined processes and improved profitability. They leverage an experienced team to negotiate competitive contract rates, terms and conditions and to provide reimbursement support. With a customized approach to matching each pharmacy’s unique business, they empower our members to stay highly competitive.

Contracting – Let an Experience Team Become A Liaison

Let a pharmacy billing team become your liaison. They negotiate contracts on your behalf to maximize reimbursement opportunity. Their strategy is to increase reimbursements while slowing or eliminating decreasing rates. They leverage our network connections and plan knowledge to help our members attain the highest level of profitability. They negotiate retail, Medicare, Medicaid, long-term care, home infusion and specialty network contracts.


Manage account receivables more simply. Reconciliation is available to all pharmacies and is an industry recognized program for claims tracking. Their service electronically verifies each payment to ensure correct reimbursement. In addition, Reconciliation offers an elite claims chase program to track underpaid and unpaid claims for TPN members. Reconciliation ensures you’re paid the right amount in a timely manner.

Electronic Fund Transferring

Your pharmacy works best if reimbursements are received in a timely fashion. With Electronic Funds Transfers for over 30 payers, pharmacy billing companies have help independent pharmacies to reduce delayed or lost checks and receive reimbursements faster via direct deposit.

Independent pharmacies are enrolled with all of the payers that currently offer EFT, as well as all future plans as they become available. Their dedicated support staff will complete all of the necessary paperwork for you; all you have to do is sign.

Medicare And Medicaid Processing

Through this specialized processing and billing solution, you can submit Part B Medicare claims for eligible durable medical equipment.

The pharmacy billing’s comprehensive suite of solutions will allow your facility to electronically submit vaccines, Medicare Part B and most state Medicaid durable medical equipment claims using your existing pharmacy software system.