Navigating Medical Billing Part 1: Understanding The Top 3 Medical Billing Challenges for Pharmacies

Pharmacies are quickly becoming the front door of healthcare. With high consumer demand for more convenient care, healthcare deserts, physician and nurse shortages, and legislative and regulatory changes to expand the pharmacist’s role as a vital care provider — pharmacies are ripe for transformation. An important part of this transformation is the expansion of clinical services offered at the pharmacy.

Recent legislative and state regulatory changes allow pharmacists to better support patients by providing a wider range of services including immunizations, test and treat for COVID-19, influenza, and strep throat, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) to prevent HIV infection, diabetes management and prediabetes consultation, weight loss management, and smoking cessation. In some states, pharmacists can also prescribe hormonal birth control.

Although clear business and patient care needs are driving pharmacies to expand their clinical services, most of those treatments require medical billing for reimbursement. There are three common challenges pharmacies encounter when it comes to adopting medical billing.

1. Limited knowledge of the differences between medical and pharmacy billing

Pharmacies have a well-built infrastructure for billing and claims management for prescriptions through the pharmacy management system (PMS).

This infrastructure is product-centric and operates effectively for traditional pharmacy products. Although the pharmacy benefit billing system through the PMS gives pharmacies relative certainty they will be fully reimbursed for filling a prescription, it does not provide any mechanism for pharmacists to get reimbursed for clinical, evaluation, treatment, prescribing, or consultative services.

Several important differences between pharmacy benefit billing and medical benefit billing exist, such as:

  • Data standard — the medical billing standard is beyond the capabilities of the PMS
  • Fields and values — those required for medical benefit billing are not supported in the PMS
  • Payors supported — the traditional pharmacy benefit billing process typically only bills in-network payors

While pharmacists are eager to operate at the top of their license and provide valuable clinical services to more patients, the current pharmacy benefit billing process simply does not support pharmacies in optimizing the full potential presented by providing a broader menu of clinical services and specialty pharmacy offerings.

2. Payor expectations for clinical services reimbursement

Pharmacy medical billing requires a more comprehensive understanding of coding and other payor requirements.

Payor enrollment and credentialing are different for medical billing. Pharmacists typically must be credentialed with the commercial payor as an ordering, referring, prescribing (ORP) provider and request that the evaluation and management (E&M) codes be added to their fee schedule to bill for clinical services with commercial payors.

Medical billing can also require more documentation and prior authorization.

For example, to bill a point-of-care test, pharmacists must have accurate results documented and the diagnosis on the claim must match the test results.

In addition, payor policies and behavior are constantly changing. This creates a more complex environment for submitting clean claims on the front end and avoiding costly denials and appeals.

3. Administrative Stress

Pharmacists need solutions that help them operate at the top of their licenses without adding administrative burdens or workflow workarounds. Across the nation, pharmacists are dealing with escalating job demands and pharmacies are struggling with insufficient staffing.

To maximize reimbursement from clinical services, pharmacies need to augment their pharmacy billing systems with supplemental medical billing capabilities that integrate seamlessly into the current workflow and increase operational efficiency while alleviating administrative workload. Processing these clinical service claims efficiently and profitably requires a comprehensive pharmacy medical billing revenue cycle management (RCM) solution.

Overcome Medical Billing Challenges with OmniSYS

The value that pharmacies provide in equalizing access to healthcare in every community is essential to the future of healthcare in America. Pharmacies need tools and solutions to make it easy to add clinical services and achieve reimbursement from the full spectrum of payors. OmniSYS, XiFin Pharmacy Solutions offers you the tools you need to submit claims for clinical services and specialty drugs covered under the medical benefit within the current workflow.

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