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Navigating Medical Billing Part 3: Utilizing Technology to Drive Revenue
February 6, 2024This blog is part of a series. Read Part 1 / 2 / 3
In the first two parts of this series, we explored the Top 3 Pharmacy Medical Billing Challenges and the Medical Billing Opportunities Pharmacies Should Leverage. This third and final post in the series explores solutions – ways to help pharmacies overcome the challenges and take advantage of the opportunities to expand clinical services and maximize reimbursement for these new services.
As pharmacies become more involved in clinical care, it’s more important than ever to have a revenue cycle management (RCM) technology or outsourced services solution to ensure maximum allowable reimbursement for the growing number of items covered under the medical benefit. To optimize the likelihood of reimbursement for medical billing, pharmacies must employ technology that offers comprehensive capabilities.
Whether delivered exclusively via technology or through an outsourced billing service, a comprehensive RCM solution will enable pharmacies to manage eligibility and benefits verification, front-end edits, and the end-to-end accounts receivable (AR) process for medical billing within the pharmacy workflow. These capabilities are critical to ensuring pharmacies maximize reimbursement for immunizations, clinical services, durable medical equipment (DME), and specialty drugs.
A Complete Pharmacy Medical Billing RCM Solution Improves Medical Benefit Management By:
- Connecting to payors for seamless claim submission through the same workflow pathway used for traditional pharmacy claim billing
- Offering provider availability and suitability data to ensure a credentialed provider is available to the patient for the requested service at the point of care
- Providing real-time coverage determination and clinical and financial eligibility clearance at the payor and plan level
- Delivering accurate patient financial responsibility estimation
- Facilitating the gathering of required documentation and prescriber information
- Maximizing workflow automation, including enabling the automation of front-end payor edits to help ensure that claims meet payor requirements before submission and minimize back-end denials
- Supporting the patient experience with easy-to-use portals for communication and information gathering
- Demonstrating proven billing expertise and results
The Added Value of Combining a Comprehensive RCM Solution With an NCPDP-based Workflow
To maximize medical billing capabilities, we recommend combining the benefits of an RCM solution with an NCPDP-based workflow for universal documentation. CareCLAIM® does just that.
CareCLAIM supports clinical services billing and enables pharmacists to submit claims for professional services, immunizations, durable medical equipment (DME), medical supplies, and drugs covered under the medical benefit within the current workflow. It manages the entire medical claims process, including documentation, billing, reconciliation, denial management, payment posting, and audit support.
CareCLAIM has the unique ability to translate pharmacy transactions into medical claims, ensuring proper reimbursement of all items covered under the medical benefit. It provides medical claims processing as an extension of the current workflow, with robust management delivering collection rates of up to 98 percent. CareCLAIM ensures payor-compliant claims and optimizes medical billing reimbursement.
As pharmacies continue to add clinical services, they should partner with a technology or outsourced services provider with expertise in pharmacy and medical revenue cycle management. The right RCM partner will enable pharmacies to take advantage of the additional reimbursement afforded through medical billing.
These partners can provide the clinical documentation, financial and clinical eligibility, connection to payors, and real-time adjudication needed to maximize reimbursements without adding work, cost, or slowing down the process. This lets pharmacists and their staff focus on clinical care and eliminate administrative burdens.
Get Started with Medical Billing
To learn more about how pharmacies can take advantage of the opportunities afforded by expanding clinical services using a medical billing approach to maximize reimbursement, download The Executive’s Guide to Maximizing Pharmacy Revenue via Medical Billing.