Among the many processes to claim a faster reimbursement rate in pharmacy billing that could be streamlined through technology, pricing verification, reimbursement accuracy, prescriber and patient dispensing verification along with prior authorization. This not only aides in improving pharmacy claims reimbursement, but your facility will also reap operational benefits.
Major factors driving complexity in the pharmacy claims process
There are three reasons why community pharmacies need to improve pharmacy claims management:
The state and federal guidelines governing who can prescribe medicines, and who can dispense them grow more complex each year. Along with that regulatory oversight of drug manufacturers and distributors, and the pharmacies face a rising compliance challenge.
The prescription drug benefits that healthcare plans provide are increasing in complexity. Pharmacy owners have to navigate benefit tiers, various co-payment and co-insurance levels, direct and indirect remuneration (DIR) fees, prior authorization requirements, and more.
Health plans continue to lower the reimbursement rates for prescription drugs. This downward pressure intimidates pharmacy reimbursement rates. One way pharmacists can ensure a higher reimbursement rates is via a thorough pharmacy medical billing and coding professionals.
Pharmacy claims management and reimbursement functions that should be automated
The dispense-as-written (DAW) codes tell clearly about the healthcare plan of the patient or a specific brand-name drug requested by them. If the DAW code is entered as a default code, the pharmacy may get a lower reimbursement for the actual brand-name drug it dispensed.
Validate the national drug code (NDC) assigned to medicines for which claims were submitted. Most often or not, drug manufacturers recycle NDCs, which means a code could become obsolete for a discontinued drug. The code edit notifies pharmacies and the patient of an obsolete NDC, and potentially increase reimbursement.
Dosage and packaging
Always check the pharmacy claim for a specific medication, its dosage and the drug’s unit-packaging for the drug and it’s recommended unit-packaging. Reimbursements for drugs dispensed with the right dosage and packaging codes will help your facility to get reimbursed appropriately.
Prior authorization services
Automating this work undertaking or letting the experts in pharmacy medical billing and coding streamlines key portions of your claim reimbursement. Remember that the prescriber and need prior approval from a health plan to give a specific medication to a patient. This helps them to avoid treatment delays and increase customer satisfaction.
By automating the pharmacy reimbursement claims through technology, and partnering medical billing and coding organization pharmacies can put themselves in a much stronger position to address the main factors of their business, which is making pharmacy claims reimbursement a streamlined process. All in all this combination helps maximize revenue, expand cash flow and generate operating efficiencies by reducing billing and coding errors that derail your income cycle.