Barriers to Ambulatory Care Pharmacy

Basics Ambulatory care pharmacy practice is the provision of integrated, accessible health care services by pharmacists who are accountable for addressing medication needs, developing sustained partnerships with patients, and practicing in the context of family and community. It involves being an integral part of an outpatient, multidisciplinary healthcare team to improve quality and patient outcomes […]


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Developing Fee Structure for Pharmacists

In the absence of any outside contracts with MCOs, all payers for service must be charged the same fee. This means that cash-paying customers must be charged the same fee that is billed to third-party payers. To charge the insurance companies a rate higher than the cash-paying customer may be considered fraud. It is important, […]


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Prescription Drugs (outpatient) Coverage by Medicare

Medicare Part B (Medical Insurance) covers a limited number of outpatient prescription drugs under limited conditions. Usually, drugs covered under Part B are drugs which patient will get at a doctor’s office or hospital outpatient setting. The patient will pay 20% of the Medicare-approved amount for covered Part B prescription drugs that they get in […]


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How to reimburse correct amount for your Pharmacy?

As a pharmacist, you may think that your most difficult tasks will include helping patients and keeping track of possible contraindications between medicines. Many pharmacists say those tasks are easy compared to getting correct reimbursements. Pharmacy billing is no simple matter, although technology removes most of the headaches. Basics of Pharmacy Billing From Pharmacy to […]


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Prescription Drug Coverage through Medicare Part D

Medicare’s prescription drug benefit (Part D) is the part of Medicare that provides outpatient drug coverage. Part D is provided only through private insurance companies that have contracts with the federal government. It is never provided directly by the government, unlike Original Medicare. Plans can vary the list of prescription drugs they cover (called a formulary) […]


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Why Prior Authorization Required for Prescription Drugs?

What is a Prior Authorization? Prior authorization for prescription drugs is required when the insurance company asks the patient’s physician to get specific medications approved. Prior authorization must be provided before the insurance company will provide full (or any) coverage for those medications. Health insurance companies pre-authorize medications in order to keep healthcare costs low. […]


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How to overcome factors impacting on pharmacy claims reimbursement?

Healthcare service providers spend most of their time and money to achieve transparency in submitting their medical claims. But the need of the hour for specialty pharmacies is to make better practice management standards, which will allow consistent recovery of aging Accounts Receivables and stabilize the cash flow. But today, aligning your charging priorities with […]


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Is your biller doing the right data handling and follow up in pharmacy billing management?

In the healthcare industry Pharmacy is an integral part just like other disciplines in this field. However, it also poses certain billing and coding challenges that may often be difficult to manage internally. Also, because certain drugs are excluded from the insurance provider’s coverage where only a few injections and adjuvant therapies allowed, it may […]


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Pharmacy medical billing: Lower Drug Prices in Medicare Advantage and Part D

CMS is allowing Medicare Advantage plans to cross negotiate Part D drug prices Starting in 2019, insurers may use step therapy to choose the least expensive drug first before moving on to another prescription. For the first time in the history of healthcare US, Medicare Advantage plans that also offer a Part D benefit have […]


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Physicians To See Increase In Medicare Part B Payment Despite 340B Cuts

The recent research reveals that about 85% of the hospitals in USA will witnessing a raise in their Medicare part B because of the recent changes in the Medicare outpatient payment charges hence; medical coding too get revised. The Medicare payment charges came into effect on January 1, 2018 which had revealed a major reimbursement […]


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