7 Things You Need to Know for Successful Pharmacy Billing

7 Things You Need to Know for Successful Pharmacy Billing

Pharmacists play a big role in physicians delivering healthcare services to patients. If you are considering offering in-office dispensing to improve your ancillary revenue generated here are 7 things you need to know for a successful pharmacy billing program.

#1 Transitional Care Management

On January 1, 2013, a new Medicare program was introduced as part of the Affordable Care Act, called the “Transitional Care Management”. This service is used for billing care management and both physicians and qualified non-physician providers after discharging patients from a skilled nursing facility, an inpatient hospital, or an observation setting.

Pharmacists qualify as non-physician providers and therefore are provided some of these services. However, in order to receive reimbursements, a pharmacist would have to meet the “incident to” requirements as well as have a Medicare recognized licensed provider submit his or her claim.

#2 Know Your State Laws

The laws in several states have now enabled a pharmacist — in collaboration with physicians — to provide medical services to patients, yet there are certain rules they must follow. For example, most states allow pharmacists to administer prescription regimens and dosages, change prescriptions if required, and provide other services that include monitoring medication, but rarely do they collaborate with physicians, which can limit their services to disease states and specific patients.

#3 Reimbursements for Preventive Services

While state Medicaid program costs for providing pharmacy, services vary from state to state, the most common service reimbursements for the 15 state providers of direct patient care Medical compensation include counseling, smoking cessation, and other preventive services.

#4 Understanding Incident to Billing

A pharmacist that works with a physician-based clinic but is employed elsewhere can use an “incident -to billing” at the physician-based clinic to bill for their services while adhering to the 9 basic requirements of Medicare.

#5 Medical Therapy Management CPT Codes

Specific negotiation contracts are required in non-institutional clinics and physician-based offices to enable pharmacist’s reimbursements for patient care services. This may involve incorporating the “Medication Therapy Management “(MTM) CPT codes.

Alternatively, pharmacist services may be included in a capitated payment model or pay for performance (PfP) incentives. Billing for pharmacy services will automatically default to Medicare regulations if no specific contracts with private payers are available.

#6 Medicare Part D Prescription Drug Plans

Depending on the state and the available “Medicare Part D Prescription Drug Plans” (PDP) at their location, a community pharmacy may be able to bill for cognitive/clinical services. Some states pay community pharmacists for providing certain levels of cognitive services to those receiving state Medicaid benefits.

However, these pharmacists may bill any provider eligible under a patient’s health insurance plan. The rules of participation may include signing a participation agreement as well as following through with any standard procedures that need to be followed to submit the bill.

#7 Medicare Beneficiary and MTM CPT Codes

MTM CPT Codes will not be recognized when a pharmacist sees a Medicare beneficiary in a physician’s office under a Medicare Part B plan. Medicare only recognizes MTM services under Medicare Part D, for which MTM services are paid administrative fees through a “Prescription Drug Benefit Plan” (PDBP).

Advanced RX Pharmacy Billing Services Are Here to Help

Health care billing process in the U.S. is very complex and difficult to comprehend for patient care services, especially for relatively new pharmacists who are still trying to grasp how to generate revenue for patient care services.

Managing a successful pharmacy billing program in-office requires expertise to navigate through an ever-changing landscape as an expert in many issues including:

  • Multiple payers
  • Nuances of which location services can be provided (institutional/noninstitutionalized)
  • Variation in regulations and state laws
  • The legislative process as regulations change or are updated frequently

Advanced RX has a dedicated team of pharmacy billing specialists ready to assist your clinic in optimizing your pharmacy billing process for maximum ancillary revenue generation through your clinic’s pharmacy services.

Learn More About Our Pharmacy Billing Services.

Enhance the revenue and value of your pharmacy today with Advanced Rx.