Auditing the Complexity of Medical Billing for Clinical Services

Good news! Pharmacists are actively billing for clinical services that extend to the evaluation and management of patients. From state Medicaid to commercial payors, agreements for pharmacist-led services are now more prevalent than ever, representing a pivotal moment in pharmacy practice to deliver high-quality patient care and grow revenue.

With these opportunities comes a new level of billing complexity. These claims demand more detailed and consolidated processing, rigorous reconciliation and denial management, and a higher focus on patient out-of-pocket expenses. This necessitates a shift towards more robust and financially based claims processing solutions.

This article will explore these critical aspects of modern medical billing and how pharmacists can navigate this intricate landscape.

Multiple Services, One Claim

One of the complexities of medical billing is the payor requirement to consolidate office visit services into a single claim. This aims to streamline the billing process but requires pharmacies to 1) document the multiple services associated with one encounter 2) submit one comprehensive claim with line-item details for each service and 3) navigate the complexities of billing via the pharmacy management system (PMS), which can pose unique challenges.

Encounter and claim consolidation are standard practice in other healthcare environments and a natural evolution for pharmacy. Because of this, it is imperative for pharmacies to be future ready by proactively adapting or augmenting their technology infrastructure, patient care spaces and processes accordingly.

Reconciliation and Denial Management by Service Line

With the consolidated claims, Explanation of Benefits (EOBs) from payors are returned with detailed line items for each service. To manage this effectively, pharmacies need the ability to:

• Reconcile payments at the service level
• Track trends in payor payments and denials by service line
• Identify and address common denial reasons to improve the process using AI
• Stay up to date with changing payor requirements to ensure compliance

Proper denial and appeals management and streamlined reconciliation are crucial to maintaining accurate financial records and optimizing revenue cycles.

Increase in the Patient’s Out-of-Pocket Expenses

As the amounts billed for services increase, payors are shifting a larger portion of the financial responsibility to patients. This trend necessitates that healthcare providers:

• Provide an accurate estimate of a patient’s out-of-pocket expenses based on their year-to-date deductibles, co-pays, and coinsurance
• Collect the patient’s portion at point-of-service
• Issue multiple levels of patient statements
• Facilitate patient payments through both digital and traditional methods
• Update and maintain accurate patient information
• Track and reconcile patient payments diligently
• Ensure follow-up on patient payment collections long after services are provided

Managing patient payments effectively is essential to maintaining financial stability and providing quality care while also ensuring a predictable and frictionless patient experience. The bottom line is that we must make it easy to be a patient seeking health services at a pharmacy, including the financial aspect of the visit. Thankfully, technology exists that addresses this potential barrier.

Claim Processing and Medical Billing Now Require a Financially Based Solution

The increased complexity of medical billing demands a shift towards comprehensive financial solutions. A future-ready Revenue Cycle Management (RCM) architecture paired with specialized services is essential to meet these demands. The ideal RCM solution should be compliant with GAAP/SOX standards and healthcare regulations to:

• Ensure referential integrity
• Provide detailed end-of-month financials and quarterly reports
• Generate accurate report net revenues
• Facilitate expected reimbursement price reconciliation
• Handle error processing summaries efficiently
• Deliver a ledger-ready closing package
• Enable thorough bank reconciliations

Putting a Revenue Cycle Management Strategy into Place

The ability for pharmacists and pharmacies to deliver and be reimbursed for health services has created an increasingly intricate medical billing landscape. A greater emphasis on detailed claims processing and patient payments requires pharmacies to adopt a comprehensive financial system that helps them navigate the complexities of modern medical billing more effectively to ensure compliance, accuracy, and fiscal health.

The need for a sophisticated, financially based solution is more apparent than ever before.

Now is the time to collaborate with an RCM partner that has deep medical billing expertise backed by people, processes, and technology you can trust. Our white paper, The Executive’s Guide to Maximizing Pharmacy Revenue via Medical Billing, is helpful in determining your next step.

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