Insure Proper Pharmacy Billing and Reimbursement

Progress in clinical practice coupled with technological advancements and counseling of patients, pharmacists are playing a very significant role in patient care. However, like all other disciplines, pharmacy billing too poses a challenge in this period of ever-increasing health care costs, insurance reimbursement cuts and recurrently changing health plans. For apt reimbursement, pharmacists must bill the patients for all supplies and services rendered while furnishing appropriate information.

Pharmacy billing process entails the following steps:

  1. NCPDP: It’s imperative that a pharmacy signs up with the database service National Council for Prescription Drug Programs (NCPDP) which allows a pharmacy to bill for services.
  2. Third-Party Relationships: Comprehending that insurance companies have their own Pharmacy Benefit Manager’s (PBM) who audit files and ensure that all parameters have been checked before claim submission is essential.
  3. Contracts: Applying for insurance contracts is mandatory. These contracts are to be signed only through local pharmacy groups. Billing to a PBM can happen only post signing as the PBM decides the amount to be paid to pharmacy, co-pays etc.
  4. Order Entry Process: The pharmacist has to collect all the relevant information and document it. This includes patient’s name/contact information/address/DoB, patient’s disease, medication, other medical history, prescription and its origin codes. The pharmacist must also collect the prescriber’s/practitioner’s information, drug information and dispense as written codes. He should complete the drug utilization review.
  5. Prescription: The source of prescription has to be validated for Medicare/Medicaid/other insurance patients. Origin codes (

0 = Unknown is used when the manner in which the original prescription was received is not known, which may be the case in a transferred prescription.
1 = Written prescription via paper, which includes computer printed prescriptions that a physician signs as well as tradition prescription forms
2 = Telephone prescription obtained via oral instruction or interactive voice response
3 = E-prescriptions securely transferred from a computer to the pharmacy
4 = Facsimile prescription obtained via fax transmission, including an e-Fax where a scanned image is sent to the pharmacy, and either printed or displayed on a monitor/screen

  1. Data Entry: To process the prescription, the pharmacy software management system has to be fed all the details such as prescriber information, third-party payer details, patient information, prescription information, DAW codes and drug information. Billing software such as Redbook, Medeil etc. offer services such as order and inventory management, and control of processes. These processes are automated and are essential for billing and communication with insurance companies, practitioners and third-party managers.
  2. Claims and Transaction process: It is advisable to verify when the patient is present (real-time) details required for claim such as eligibility for insurance, co-insurance/co-pays/deductibles, benefit caps, address (claim) and formulary. The process is to submit the claims, and try and ensure real-time claims settlement.. Many a time’s pharmacy is billed to insurance together with hospitals when they send their insurance claims. At this point, pharmacy can get affected due to incorrect claims. And as pharmacy follows the same HIPAA rules, they require a higher degree of accuracy (especially during resubmission).
  3. Billing/Third party payer arbitration: The pharmacy through its computer program fills the prescription, patient demographics and then sends it to PBM. Thereafter, the status of paid/denied is made known to the pharmacy. If accepted after examination of the patient’s benefits, the pharmacy is made aware of the amount to-be paid and co-pay information in real-time by the insurance payer. This usually occurs between 30-60 days within the specific time frame set. This is supplemented by a remittance advice (RA) or EoB. If denied, the pharmacy must first contact the PBM to resolve the issue and begin the process again.
  4. Point-of-Service: Accounting and bookkeeping are two vital instruments of pharmacy. In the case of approved payment, all records of the medication must be maintained with respect to proper filing, check, and the doled out prescription. Pharmacists must collect the payments and counsel on the medication administered.

The team at Medical Billers and Coders specialize in pharmacy billing. They cater to all forms of pharmacy billing services such as clinical, home care, managed care and radio. As certain drugs are not included in reimbursement, the team at Medical Billers and Coders can distinguish this from the injectable or adjuvant therapies which fall under reimbursement schemes, and hence, take charge of the entire process of claim preparation, submission, data handling, admin related activities, follow-ups, and audits, and aid in improving the overall financial strength of the pharmacy.