Do You Really Need A Specialty Pharmacy Billing Company?

Specialty Pharmacy Billing – A Study in Complexity

Prior to starting to talk about the need for a specialty pharmacy billing company, it will be helpful to survey the current scenario. Specialty pharmacies, like other kinds of pharmacies (such as retail pharmacies or compounding pharmacies, for example), are governed by billing and reimbursement rules that may look similar on the outside. In fact, they are indeed quite alike in many respects. However, in the case of a specialty pharmacy, these rules are stricter and frequently, more elaborate.

The main reason for this is the expensive nature of the medication that these pharmacies deal in, often running into thousands of dollars for a single dose. But there is more to it.

Let’s start at the beginning

To attempt a simple explanation, one might say that specialty pharmacies prepare and dispense ‘specialty’ drugs. These are essentially high-cost, high-complexity, and high-touch medications, meant for use by patients diagnosed with chronic, rare, or complex diseases (e.g. cancer, multiple sclerosis, rheumatoid arthritis, hemophilia etc.)

Besides the intrinsic difficulties and complexities associated with preparing them, these medications often require special handling, storage, and administration, as in the case with injectables, biologics, or gene therapies.

All these factors bring about a compounded effect on the general price of specialty medication. The stakes are high and consequently, all the parties involved – the pharmacy, the patient, and the payer – need to tread carefully.

Playing Under a Sterner Referee – Exploring Challenges

The avenue of revenue generation is not an easy one for specialty pharmacies. It is strewn with challenges. And they all begin with prior authorization (PA) and benefit verification.

Specialty medications, very often, need to be prior authorized by insurers before they can be dispensed. This is necessary to make sure that they are ‘medically necessary’ and are covered under the patient’s health plan. Specialty pharmacies, therefore, must work closely with providers, insurers, and pharmacy benefit managers (PBMs) to expedite approvals and avoid delays in treatment. Failing to obtain a PA (as may happen if a request is denied or delayed), can put pharmacies at risk of losing reimbursement, and may even lead to increased patient non-adherence.

Incidentally, it is interesting to note that specialty pharmacies frequently play a key role in securing financial aid. This is done through copay assistance programs offered by drug manufacturers, patient assistance programs (PAPs) available through nonprofit organizations, and alternative state or federal funding sources. This assistance can be immensely valuable because these drugs typically cost a fortune.

A common impediment in ensuring a smooth billing experience is the confusion arising from the fact that specialty drugs may be covered under either medical or pharmacy benefits. Specialty pharmacies must accurately determine the correct benefit category to be able to submit clean claims that will not be denied. Conducting real-time eligibility checks before dispensing medications is also necessary.

The Case for Specialty Pharmacy Billing Company

Billing for specialty medication is anything but a walk in the park. Obtaining the necessary authorization before dispensing the medication, diligently scrutinizing the patient’s coverage details, complying with payer norms, understanding reimbursement caveats – there is a lot to handle. No wonder, a professional specialty pharmacy billing company is in such demand these days.

Even the slightest overlook in billing can lead to a claim getting rejected, or attracting audits. And all this can take a serious toll on the revenue. To minimize such unpleasant possibilities, having a competent biller by your side can be a real lifesaver. Outsourcing your pharmacy’s billing tasks to a professional specialty pharmacy billing agency can actually go a long way in reducing errors, saving time, and ultimately, improving the cash flow.

Adherence concerns can be a major headache. Adherence and outcomes tracking have become key expectations from payers, as value-based care models require pharmacies to ensure that patients take their medications as prescribed. It, therefore, makes a lot of sense to offload such worries to a capable partner.

Most such specialized billing organizations offer a range of services other than basic billing, such as helping specialty pharmacies implement patient engagement programs (including calls, text reminders, and adherence monitoring) to support patients throughout their treatment. It is important to keep in mind that specialty medication comprises high-touch drugs, and appropriate patient education is often necessary for the best outcome.

The Search for the Perfect Partner

While opinions may differ on what constitutes a ‘perfect’ billing partner, there are some aspects that must be considered. Of these, the two most important considerations are price and experience. A strong familiarity with payer norms and regulations (encompassing both private and federal payers) is also a highly desired trait in a prospective partner.

Billing for high-cost specialty drugs – with a view to securing maximum reimbursement – is a challenging and demanding job. It needs professional acumen, the right set of skills, and a good deal of hands-on experience. Make sure that you check all these important boxes before signing up with an external biller.