The pharmacy revenue cycle is complex, making reimbursement challenges common.
The pharmacy revenue cycle has many complexities. Common reimbursement challenges for specialty pharmacies range from eligibility and coding to billing and collections.
Let’s discuss four common reimbursement challenges for specialty pharmacies.
1. Your old A/R is getting older.
Is your A/R quickly aging? Unfortunately, infusion pharmacies face this issue frequently. Your oldest accounts might even exceed 90 days, a common problem that we discussed here. You also probably know your high-dollar A/R requires special attention, but lack the resources needed to apply pressure to these accounts.
2. You have challenging accounts or payers.
Specialty pharmacy providers often struggle with certain accounts or insurance payers. If your billers are overloaded, they may miss key patient information such as date of birth or diagnosis. They might fail to verify benefits or coverage criteria. As a result, you might spend extra time addressing these accounts and dealing with frustrated payers.
For example, Medicare requires signatures on delivery tickets. So, you may see delays in the intake process when tickets go unsigned.
3. You lack experienced insurance collectors.
Do your billers make these common and costly mistakes?
- Incorrectly coded items
- Improperly calculated billing units
- Modifiers added incorrectly
- Incorrect payer billed as the primary
- Improperly set up billing systems
If so, you know that these errors impact time, money, and motivation. Your frustrations rise and your team loses morale.
4. You audit concerns from Medicare or other payers.
Now, these billing errors lead to audits from key payers. Audits require considerable resources. When you run an already lean team, concerns from Medicare or other payers only adds to your plate — and your pain.
