Navigating the Complex World of Specialty Pharmacy Billing

Specialty Pharmacy Billing is specialty in nature and requires advanced knowledge of the treatment provided as well as the medical and financial dynamics involved.  Basically dispensing specialty/mostly high-cost, high-complexity medications, or medications intended for the treatment of chronic or life-threatening diseases such as cancer, multiple sclerosis, and rheumatoid arthritis; managing billing for specialty pharmacy can be quite complex. Also while many of the medications provided through specialty pharmacies are high in price, whereas their administration involves specialized services in patient counseling, management of medication, and close coordination with healthcare providers. 

Given the complex nature of these therapies, while billing for a specialty pharmacy one needs to keep 5 pointers in mind: 

• Knowledge of Medication and Costs and Reimbursement: Specialty medications are truly expensive; in fact, doses can often be in the hundreds and thousands of dollars. These drugs are complex to bill, and it is important to understand cost issues related to insurance and copay assistance for the patient. Specialty pharmacies need to be able to negotiate these payor systems and accompanying structure, including Medicare Part B, to ensure that their patients don’t go without needed medicines because of cost. 

• Coordination with Healthcare Providers: Specialty pharmacy billing involves the coordination in communication among the pharmacy, healthcare provider, and insurance in a seamless manner. This is pivotal in enabling verification of insurance coverage, preauthorization of drugs, and verification that medications are correctly billed. Also it is vital to remember, efficient and proper and fluent coordination allows patients to access their medications with as little delay as possible, a critical element in the management of chronic conditions. 

• Patient Support and Counseling: Specialty pharmacies may also provide counseling to patients as part of educating the patient regarding their medications and managing any possible side effects. For billing purposes, all patient interactions must be recorded and reflect certain specific payer requirements. Specialty pharmacies can also extend financial aid for their patients to defray medication costs, in which case these programs should be integrated into the billing process. 

• Adherence to Regulatory Requirements: One of the most notable things about specialty pharmacy is its adherence to the many regulatory requirements set out by authorities.  Also, as specialty pharmacies consistently bill in compliance with all CMS requirements and be prepared for compliance during audits or inspections. This is because, without it, pharmacies may experience costly financial penalties and interruptions in patient care. 

• Leverage Data Analytics: Specialty pharmacy billing greatly involves the use of data analytics. By analyzing the data on billings, pharmacies are able to point out trends and patterns indicative of their problems, which could be underpayment, delays in payment, or probably fraud. Analytics can also be utilized in ensuring optimal practices of billing and generally improving financial performance. 

How to End Your Specialty Pharmacy Billing Issues: 

Specialty pharmacy billing essentially requires great expertise, precision, and understanding of both health care and financial topographies. Sunknowledge Services Inc. offers comprehensive billing solutions, totally catering to the unique needs of specialty pharmacies. With over 15 years of experience in revenue cycle management, Sunknowledge ensures all aspects of billing, right from insurance verification to reimbursement, to be processed with utmost efficiency and accuracy. Still confused? Call our expert and let us help you us in enhancing denial reduction efforts with the rise in cash flow provision.