Don’t Leave Hard-Earned Money on the Table
Clean, accurate claim submissions can be complex feats in today’s fast-paced pharmacy environment. While few in the industry would dispute this assertion, industry best practices consistently point to an improved revenue outlook when the right tools and workflows exist.
Major pharmacy chains currently leverage the power of claim edits to reduce common errors such as inaccurate pricing or dispense as written codes (DAW). The answer lies in having the right infrastructure and processes in place to identify and eliminate errors before claims are ever submitted. This framework has been proven to elevate revenue by more than $11 per claim submitted in many cases.
Pharmacies must keep pace with ongoing updates to drug prices, especially when you consider the fact that, on average, almost two million transactions per month are submitted with incorrect pricing. Proactive management of price revisions in a fluid pricing landscape can help ensure pharmacies are accurately reimbursed for medications dispensed. When high-cost, high-volume brand name drugs undergo price corrections in the market, pharmacies need to position themselves one step ahead of changes to maximize revenue.
While DAW code disparities equate to $39 million in lost revenue every year, a simple upfront edit to identify errors can minimize the impact. If a prescriber chooses a DAW code indicating that a generic drug substitute is allowed but the pharmacy fills a prescription with a brand-name drug, payers will naturally reimburse at the lower generic rate. Pre-configured edits eliminate the potential for these inconsistencies.
Similarly, recurring package quantity mismatch errors can be minimized through claims edits, improving the outlook on revenue and audit activity. For instance, it’s not uncommon for a busy technician to overlook the fact that an inhaler is billed by the number of grams it holds rather than the inhaler itself. Claim edits can enable the inhaler to be billed for 17 grams rather than “one,” which would deliver only one-seventeenth of the total reimbursement. Eliminating this error can also boost pharmacy competency and help reduce the risk of audits.
An advanced claim editing engine can address all of these issues and more by automating the process of cleaning claims through a series of pre-configured edits. Common areas where mistakes occur, such as DAW codes, incorrect pack size and use of discontinued NDCs, can be proactively reviewed and corrected before a claim is submitted. Ultimately, this simple but highly-effective process promotes financial, administrative and legal compliance as well as revenue optimization.
Alongside the right technological infrastructure, pharmacies will want to implement training and workflow best practices. Ongoing education regarding regulatory guidelines should be a priority in all pharmacies to minimize the potential for errors. Equally important is having solid communication and oversight guidelines in place to elevate accuracy. Often, pharmacists and technicians working together can become overly comfortable with a routine, and that can lead to complacency. Rotating pharmacists and technicians to heighten the effectiveness of oversight may improve the outlook in some cases.
Dozens of data elements exist on every pharmacy claim, opening the door to inaccuracies that misrepresent medication dispensing. Even one error can cause a claim to be voided or diminish revenue. Technology to address claims edits helps evaluate pricing, eliminate errors and help prevent unnecessary margin erosion.
Jonathon Kopf is Director of Pharmacy Network Services for Change Healthcare responsible for leading the technical operation of all pharmacy network products and services including switch, claim editing, manufacturer discount programs, cash claim adjudication, REMS, and data delivery. He has worked in the pharmacy industry for more than 15 years. Prior to joining Change Healthcare, Jonathon spent ten years in various roles at Anthem (formerly Wellpoint) in their pharmacy benefit management division, and five years as a pharmacy technician at a mid-sized retail pharmacy chain. He holds a bachelor’s degree in management with a health organization focus from Texas Tech University.