9 Critical Steps to Significantly Improve Specialty Pharmacy Billing

With the United States accounting for 40% of total global health expenditure, patients benefit from scopes to decrease the cost of care while specialty pharmacies eye amplified revenue. However, these revenue-based benefits only apply when clinical services are optimally reimbursed. Unfortunately, one cannot always say that in the case of specialty pharmacy billing which can be challenging.

Are frequent billing errors and delayed payments rupturing your practice’s overall revenue? You are not the only one facing such a situation. According to Becker’s Hospital Review, almost 80% of medical bills contain errors and such inaccuracies significantly impact the bottom line for most medical practices. Some of the critical challenges that create bottlenecks for specialty pharmacy billing success rates are given below.

Critical Challenges with Specialty Pharmacy Billing

• Lack of understanding of specialty billing process: With the paradigm shift to ensure excellent clinical care in the healthcare domain, specialty pharmacies have to deal with increased clinical responsibilities. Things become more challenging when pharmacists also need to deal with complex billing responsibilities. Additionally, pharmacy professionals often lack adequate knowledge about specialty pharmacy billing, thus causing billing errors and poor cash flow. Having a clear understanding of billing operations is paramount for a healthy revenue cycle.
• Frequent changes to insurance reimbursement schedules: Federal and private insurance companies often change their reimbursement schedules. Most specialty pharmacies struggle to figure out when they would be reimbursed for the provided care. The uncertainty and confusion around reimbursement time often create delays in cash flow and hamper the overall revenue cycle management.
• Resources with limited knowledge and experience: Without adequate knowledge and expertise, specialty pharmacists struggle to receive reimbursements for the provided services. Additionally, the majority of practices do not have a dedicated billing team. This results in botched billing operations, causing substantial revenue leakage at the end of the financial year.
• Changes in the specialty pharmacy industry: The pharmaceutical industry has changed a lot recently, creating new roles, tasks, and challenges for pharmacy employees. Billing for a specialty as dynamic as this, is naturally going to be a strenuous affair.

The good thing is that optimizing the billing operations in your practice can substantially amplify your bottom line, allowing you to put full effort and time into patient care and spend minimum time worrying about administrative and collection related tasks. Here are 10 highly effective tips for optimizing your medical billing foundation.

9 expert tips for optimizing medical billing

1. Verify patient information carefully: Before you supply the medication, verify the patient’s insurance information carefully. This information should typically include all of a patient’s critical demographic and insurance coverage details. Implementing a robust eligibility verification method will help minimize errors and denials afterwards.
2. Stay informed about the latest coding and compliance guidelines: The majority of billing errors originate from inaccurate coding. Make sure your in-house coding team codes accurately to keep denials at bay. Apart from checking the latest coding guidelines, you should also stay on top of the latest compliances like HIPAA and other guidelines. Federal payers like Medicare, Medicaid, and other private payers update their billing guidelines often. It always pays to check their websites regularly to ensure that you are not missing out on any crucial update.
3. Set clear billing process guidelines: Establish standardized medical billing rules and workflows to avoid confusion and errors. Implement clear guidelines for patient registration, eligibility verification, coding, prior authorization, claim submission, payment posting. Make sure all these guidelines are well-communicated among your staff.
4. Establish clear rules for patient payment: Set clear payment rules to collect from your patients. These should include your payment expectations and letting your patients know about copays or out-of-pocket payments required of them. You should communicate these rules clearly through forms, bill statements, patient portals web pages, etc.
5. Timely Prior Auth approvals: Many drugs and medications require you to take prior authorization approvals from the patient’s Health Plan. Receiving PA approvals on time always enables your practice to receive timely reimbursements and avoid a lot of confusion or disappointment afterwards.
6. Implement a claim submission process: It is important to have a template for submitting insurance claims. You need to create the template based on the best practices. Such templates ensure that all claims are submitted uniformly.
7. Develop a system for tracking provided services: You need to streamline a method to efficiently keep track of what drugs were administered to which patients. It enables you to track proper documentation of all the services provided. Furthermore, it helps you to know which services have been successfully reimbursed and which ones are still pending.
8. Manage denials: Establish a dedicated team for managing denied claims. The team should use advanced analytics and metrics to find the root causes of denials, identify patterns, and implement ways to mitigate them. Also, regular follow-ups with the payer to receive the full amount and resubmitting the denied claims with necessary corrections can help in getting fast approvals.
9. Provide regular pieces of training and education to your billing staff: With a lack of adequate process knowledge being one of the major barriers in the specialty pharmacy billing process, providing regular training to your billing staff is a crucial step. Trained staff members are always better equipped to manage all the nuances of specialty pharmacy billing, thus ensuring maximized collections. The key areas in specialty pharmacy billing where your staff may need training are

• Documentation and authorization process
• Requirements for accurate claims submission
• Understanding reimbursement policies from insurance companies
• Sound coding knowledge
• Effective communication with payers

Unfortunately, most specialty pharmacies find it a costly and time-consuming proposition to build a dedicated in-house billing team from scratch. As a perfect solution, practices that choose to outsource their specialty pharmacy billing to professional RCM companies can see solid revenue, minimized errors, and improved patient care.

If you are considering outsourcing specialty pharmacy billing, Sunknowledge, as one of the leading medical billing companies, has got your back. Outsourcing your billing, coding and RCM tasks to us enables you to enjoy

• Cost efficiency
• High productivity
• Clean claims
• Instant access to verified experts
• 100% compliance assurance
• Excellent patient-satisfaction score

At Sunknowledge, we offer specialized RCM support for specialty pharmacies of all sizes, including eligibility verification, prior authorization, coding, denial management, and accounts receivable recovery.

Schedule a demonstration with our experts to see how our services can become an extension of your operations at the best price. Take advantage of the Sunknowledge opportunity today!