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Improving Pharmacy Claims Reimbursements – Outsource Now

Pharmacies continue to scrutinize their income cycle in today’s complex healthcare environment. As rising drug prices and declined reimbursements contribute to shrinking margins, pharmacy billing and coding is one place where industry leaders should look to make a positive impact on revenues.

Today, if you review the challenges that a pharmacy faces in regards to revenue cycle management and ask industry insiders as to which one is their biggest challenge, the answer is:

  • Regulations and market challenges – 30%
  • Payor practices – 20%
  • Technology – 50%

Well, it’s not a surprise, technology topped the list as it was also the main region that pharmacy leaders said would most benefit their organization.

Health care facilities, especially pharmacies considering outsourcing their services should have a clear understanding of what they want to accomplish. Their consideration should include, an internal needs assessment, a cost scrutiny, and a careful review of possible workers. The organization should also examine the potential long-term consequences of outsourcing and also the short-term outcomes expected during an initial performance period.

Factors influencing outsourcing

Various influences and market forces that may underwrite towards outsourcing pharmacy billing being considered as a business option include the following:

Operational and Organizational

  • Re-engineering and downsizing initiatives
  • Alliance and integration of health systems and departments within health systems
  • Exclusion of or reduction in the size of outdated departments
  • Restructuring around patient-focused care
  • Carrying out automated pharmacy systems and the need to reorganize medication distribution functions


  • The scarcity of nurses and other health care professionals
  • An absence of pharmacists with specific experience and capabilities

Cost-Control and finance

  • Controlled budgets
  • Augmented operating costs
  • Increased drug costs
  • Increased importance of measuring performance in terms of staffing and costs instead of clinical outcomes


  • Bigger expectations of and pressures from sanctioned pharmacies and consumer groups to improve the quality of patient care

Governmental and Regulatory

  • Increased numbers of persons dependent on federal, state, and local governments for health care
  • Reduced capacity of federal, state, and local governments to finance health care
  • Better government controls on reimbursement for health care


  • Increased competition among health care facilities
  • Greater competition between suppliers of pharmaceutical products and related services

Why Outsourcing?

Pharmacies that conduct in-depth assessments may say that outsourcing either is or is not a good option for meeting their needs. Motives for their decision will vary according to a number of factors.

Reasons to outsource pharmaceutical operation


  • Ease the alliance of pharmaceutical services in integrated health systems
  • Resolve operational incompetence (by improving medication distribution systems, designing new pharmacy workspaces, decreasing medication dispensing and medical billing errors, and improving information systems)
  • Permit the organization to acquire additional resources and skill to carry out other changes (restructuring of existing staff to pharmaceutical care roles in patient care areas)
  • Arrange for educational programs for patients and their families and for health care staff


  • Help the facility to staff hard-to-fill pharmacy positions
  • Allow the facility to reach ideal staffing levels for achieving productivity targets

Control the finances

  • Regulate the cost of the organization’s services
  • Control or reduce employment costs (by shifting the cost of employees, benefits, and liabilities to a contractor)
  • Empower the pharmacies to acquire an outsourced firm who will share the risks associated with operating the pharmaceutical services
  • Evade the cost of purchasing and maintaining pharmacy equipment
  • Avoid the cost of the physical makeover (by using the equipment of the outsourced firm to provide specific services for which remodeling would be required)


  • Allow the pharmacies to maintain or expand the quality of patient care (by expanding clinical services and pharmaceutical care, creating new services, and finding specialized expertise in pharmaceutical care)
  • Offer support for the medical and nursing staffs and expand the all-important physician, nursing and pharmacy collaboration.

We are a group of medical billing experts who offer comprehensive billing and coding services to doctors, physicians & hospitals. We provide A to Z billing and coding solutions. Medisys Data Solutions RCM solutions ensure that the providers recover every $ they are entitled to. Our vision for the providers is “You Cure. We $ecure”

You can reach out to us at or 302-261-9187

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