Pharmacy Billing and Reimbursement

Conventionally, pharmacist compensation has been majorly concentrated on collecting payment for the products’ provision, such as prescription medications. Nowadays, pharmacists possess an extended practice opportunity and the pharmacy profession has integrated different clinical avenues into regular patient care such as medication therapy management, chronic disease management, and care transitions interventions. A prescription has multiple stages of compensation while traveling from pharmacy to patients’ hands, for pharmacy as well as patients.

Knowing the flow of prescription from entry to adjudication can be complex, however, it is fundamental to know the functionality of the pharmacy billing process. In order to sustain these services, pharmacists have to be able to get reimbursed for the time and resources involved to enhance outcomes and patient care. Our payment resources are structured to support you to know current and future opportunities to be reimbursed for offering particular patient care services.

Steps Involved in the Pharmacy Billing Process:

  • Tracing

Tracing of the prescription (point of origin) via codes, the pharmacy management software entered POC codes that range from 0-4 denoting e-prescribe, fax, verbal, and written.

  • Collecting Data

Collecting insurance data of patients such as BIN number, member ID, group number, and type of coverage whether it is primary or secondary.

  • Steps of Data Entry

Entering essential billing information like prescriber information with NPI number (national provider identifier number) and DEA

  • DAW codes

DAW codes are entered for substitution of medication if necessary

  • Drug Information

Drug information along with medication name and its National Drug Code (NDC) should be reviewed

Pharmacy Claim Submission

When a pharmacy claim is transmitted, it does so through a switch vendor that is vendor, which makes sure the transmitted information follow the National Council for Prescription Drug Programs (NCPDP) standards before it reached the Pharmacy Benefit Manager (PBM)

Rejected Submissions

The pharmacy or the prescriber will require to communicate the PMB or the third-party payer in order to get approval

Basic Reasons for Declined Claims

  • Improper insurance information
  • Untrue quantity
  • Non covered medication requiring Prior Authorization
  • Inappropriate days supply
  • Refill too early

Process of Adjudicating

Process of adjudicating is completed quickly and electronically. When a script is confirmed, then the claim is adjudicated by the payer, at the same time cross-references the patient insurance advantages for coverage, and specifies benefits that the patient will get for the prescription.

Pharmacy Reimbursement- How Pharmacies get compensated

Pharmacy reimbursement is termed as a shadowed essential element of processing prescriptions of patients. Pharmacies receive compensation bases on what medications are distributed and what strategies the medications are sourcing from.

  • Medicare

Part D sponsors commonly known as health plans individually negotiates pharmacy payment and price discounts with pharmacies as well as manufacturers.

  • Medicaid

State Medicaid agencies supervise Medicaid and compensate pharmacies for drugs. Jointly, States and the Federal Government, under wide Federal guidelines find out pharmacy reimbursement. States too get federally-authorized Medicaid drug rebates and could negotiate with manufacturers for extra funds.

  • Private

Generally base reimbursement formula on average wholesale price. PMB mediates compensation with dispensing fees independently with pharmacies, which is generally 40% lesser than the general dispensing fee charge.

Third-Party Reimbursement Systems

Third-party reimbursement systems are used in the pharmacy prescription drug costs’ payment.

  • Pharmacy Benefits Manager (PBM)

Insurance companies appoint a Pharmacy Benefits Manager (PBM) in order to process the claims for the members of the insurance company. The PBM will generally use a formulary, a list of permitted drugs, to help contain costs. The formulary may be open as well as closed. An open formulary permits for coverage of non-formulary drugs, however, at a greater price. While a closed formulary does not allow coverage of non-formulary drugs.

  • Coupons

Drug manufacturers for certain drugs may issue Coupons. As far as coupons are concerned, either it may cover total drugs’ cost or partial drugs’ cost. These coupons could be available only for self-paying patients but also for patients with insurance.

  • Self-Pay

The third-party payer issues a prescription drug program that some patients do not possess. Nevertheless, some patients can have their salary account, which they may utilize to help balance their drugs’ costs. Flexible salary account utilize pre-tax dollars in order to pay for covered elements. States to state plans are different.

Outsourcing your pharmacy billing responsibilities could help you to mitigate today’s auditing hassles and secure your financial outcomes. We are experts in offering medical billing services all over the country. If you are ready to decrease your denial rate, enhance revenue performance, and get reimbursed for pharmacy billing we can help you. Contact us to learn about how we can offer you pharmacy billing services that support your practice.