Pharmacy Billing: Measuring Value Today and Tomorrow

Since its inception, the pharmacy sector of healthcare has been faced with various challenges which have threatened the quality and the affordability of care for its patients. These challenges often resulted in administrative as well as billing burdens impacting pharmacy operations, unique accounting, bookkeeping, and even patient safety.

Though technology has removed most of the headaches of Pharmacy billing, still there were a lot of challenges in Pharmacy Billing such as:

  • Financial Integrity: It’s important to ensure that the amount paid by the insurance company and the copay is correct and match the amount billed in the final claims adjustment.
  • Understanding third-party contracts: It’s important to understand the third party contracts and decide whether to sign them or not.
  • Many a time, patients did not get the medications needed because they could not afford to pay for their prescription at the time of sale

As a result, solutions started evolving from needs – from health plans entering into a contractual arrangement with the pharmacy to a single form for claims submissions (Universal Claim Form (UCF)), forming the genesis of the National Council for Prescription Drug Programs (NCPDP). The pharmacy industry continued to deal with new challenges and NCPDP became a permanent forum for consensus-driven solutions to be developed. Following years, Pharmacies became overwhelmed by the growing receivable problems as their cash business transitioned to third-party payer plans. And the payers faced yet another challenge of the increasing number of paper claims that were processed manually at huge administrative costs. Thus came into existence a pharmacy billing software and online pharmacy billing services.

With this, the pharmacies knew the status of the patient, his drug eligibility for coverage, copayments etc even before the prescription was dispensed; Also, real-time clinical alerts, such as potential allergies or interactions with other drugs could be provided to pharmacists who could coordinate with the prescribing physician prior to dispensing the medications thus increasing the overall patient safety.

Today, real-time claims submission and the response has solved a myriad of issues and have proven to be the most effective solution for the pharmacy industry. The entire electronic communication cycle now takes less than five seconds. Technology, no doubt plays a very essential role in communicating accurately with insurance companies, third-party managers and physicians.

A collaborative model for future needs:

The pharmacy industry under NCPDP continues to build effective solutions for the challenges being faced in pharmacy services of today and tomorrow. NCPDP has expanded to include representatives from various specialized segments of the healthcare industry that includes long term care and worker’s compensation.

With a focus on electronic prescribing and other supporting transactions, NCPDP has improved the overall patient care and has moved pharmacy services from traditional paper prescription to a model where the physician or the prescriber electronically transmits the prescription to the pharmacy. As a result, it has:

  • Eliminated the errors that occurred due to improper interpretation of handwritten prescriptions,
  • Eliminated the errors due to similar sounding or similar looking drug names,
  • Reduced the need of pharmacy billing specialist calling the physician by providing the drug utilization and formulary review results to the physician before sending to the pharmacy,
  • Increased patient satisfaction and compliance by making it convenient for patients to pick up a prescription without any wait in the lines.

The foremost item acknowledged to improve a patient’s quality of care is its complete medication history in Electronic Health Records (EHR). The electronic prescribing functionality has been enhanced and is being utilized by the industry for medication history exchanges to populate EHRs.

The collaborative model of NCPDP was used to build this information exchange and supports NCPDP in its work with the Health Information Technology Standards Panel (HITSP) to create total healthcare solutions based on standards. The pharmacy industry has proven that any problem of healthcare can be solved through collaboration thus providing a more cost-efficient and patient-centered system.