by Shelley Hansell, SVP Client Relations & Revenue Cycle Product Management
As a pharmacist, you have more opportunities than ever before to use your knowledge and expertise to improve clinical outcomes for patients. Not only are patients seeking more convenient, lower-cost settings to receive care, the industry has also embraced an elevated clinical role for pharmacists.
Because you assume the role of provider in clinical encounters, reimbursement looks very different than it does for your standard pharmacy transactions. Here are three key challenges when it comes to capturing clinical services revenue, and recommendations on how you can overcome these challenges.
(1) Documentation requirements vary by encounter and payer
Challenge: Proper reimbursement for clinical services starts with documentation. Due to the nature of these encounters, payers have the same expectations for you as they do for physicians and other practitioners who provide direct patient care. Each payer requires certain documentation elements for different encounter types, and missing elements can put your reimbursement for the entire encounter in jeopardy.
Recommendation: Attempting to manage all of the different documentation requirements by payer would be a challenge to say the least. The right technology will guide you through all of the necessary documentation elements for reimbursement based on the payer you select at the beginning of the encounter. You should look for a technology that will prompt you throughout the encounter to document appropriately based on state regulations and specific payer requirements. For example, Medication Therapy Management (MTM) documentation requirements vary with each payer. Documentation requirements for other encounter types such as hormonal contraceptive therapy also vary in a similar manner.
(2) Clinical documentation and billing are intertwined
Challenge: Documentation drives billing when it comes to clinical encounters. For example, many pharmacist-driven clinical services are billed based on the amount of time spent with the patient, which must match your documentation. Leveraging different technology solutions to document and bill, or attempting to document and bill manually is a recipe for disaster when it comes to reimbursement. Documentation and billing are two sides of the same coin – there are a number of requirements and rules from payers related both to documentation and to billing.
Recommendation: Because payers link documentation directly to reimbursement, your solution for managing both of these elements should do the same. A billing-enabled pharmacy EHR will protect your reimbursement by prompting you to complete all of the necessary documentation elements for reimbursement, then allow you to bill seamlessly from the same platform. A single platform is key here.
(3) Medical benefit claims are different than pharmacy claims
Challenge: Much of the complexity related to clinical services lies in the fact that they are reimbursed through the medical benefit. These transactions involve a direct relationship with individual payers, each with a different set of rules and requirements. Medical benefit claims are also not processed in real-time, which means it can be weeks or even months before you know if the claim will be paid.
Recommendation: During the claim adjudication process, it is essential to have a built-in set of rules for eligibility, coverage and other criteria for each payer, allowing you to know who qualifies for a clinical service, how much you’ll be reimbursed for the service and the amount to charge the patient. Those rules should be applied to the claim in real time, giving you the ability to correct any potential issues before submitting the claim. This process ensures that the claim includes all of the required information and increases the likelihood of receiving the expected reimbursement, reducing much of the risk around medical benefit reimbursement. Without the real-time knowledge, you’ll be left sending invoices to patients after you’re reimbursed, similar to a physician’s office.
As provider status for pharmacists expands, a growing number of clinical services covered under the medical benefit will create new ways for you to serve your patients and grow your business. Putting the right documentation and billing infrastructure in place means you will face fewer obstacles to bringing new revenue-generating clinical services to your patients.
Shelley Hansell, EVP Client Relations & Revenue Cycle Product Management
Shelley serves as executive vice president of client relations & revenue cycle product management, and in this role she is responsible for building client partnerships and implementing products and services that mutually grow businesses.