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OmniSYS, XiFin webinar focuses on overcoming the complexities of medical billing

The webinar highlighted how pharmacists can build a strong foundation to overcome the complexities of medical billing and scale their clinical services.

Drug Store News hosted the "Unveiling the Medical Billing Blueprint for Establishing a Future-Ready Pharmacy” webinar, featuring Harley Ross, chief commercial officer, XiFin; Sandra Greefkes, vice president of product and partner marketing, XiFin; and Ashley Keller, product manager, clinical services, OmniSYS, XiFin Pharmacy Solutions. 

Greefkes opened the discussion about the digitization of the patient journey, noting that people shortages and the continued need for socialized skill sets will persist. "All complicated challenges require a multi-faceted approach that not only works on the people part of the solutions, but also the processes and technology that help things be more efficient, less laborious and even perhaps a delightful experience for the patient," she said.

Pointing out that as you consider expanding services in your pharmacy, or changing things so the services you provide are done more efficiently and in a patient friendly way, Greefkes advised to think about what types of things can happen before the patient ever walks into the pharmacy. "If they make an appointment, does your process and logistics support scheduling of service at a time when the pharmacist is credentialled and is in the store at the right time?" she said.

Noting that the company did research in the last three months of 2023, surveying over 500 people, Greefkes said there was a lot of discussion regarding broadening the scope of practice for pharmacists. "We explored what expansion looked like, in 12 to 36 months and what the barriers are to expansion, what kind of revenue impact that were having and they were getting from a pharmacy perspective. We also looked at the people process and technology considerations," Greefkes said.

What services are pharmacies offering today? 

Greefkes revealed that almost 75% of respondents indicated they were already offering immunizations, between 30% and 40% were providing chronic care management, health and wellness consultations, test and treat, as well as supplying DME. "Close behind was a grouping around diabetes self management training, specialty drugs, medical supplies and birth control, which were all in the upper 20% range. As we move forward, we explored what they were planning on expanding into. In some cases, they are providing more services that they already launched, in other cases, it was adding services," she said. 

The company also asked respondents, what clinical services do they plan to start offering or are offering and expanding within 2024 year and the first half 2025? "Immunizations will continue to be a primary service and will continue to expand, whether seasonal or based on age-related clinical eligibility. Chronic care management of asthma, hypertension are the next higher areas of investment, with health and wellness consultations, weight management or smoking cessation," Greefkes said. 

Rounding out the top five expansion areas, are offerings related to diabetes self management training, as well as a broader offering of diagnostic testing, hormonal contraceptives and consulting, as well as specialty pharmacy, "that also are areas of investment in the next three years," Greefkes added.

When it came to exploring barriers to expansion of these clinical services, Greefkes said, "Out of 11 options we offered, reimbursement was ranked number one overall. Not far behind, were staff limitations and time constraints. At the bottom of the chart, which means they were ranked lowest, was technology limitation. About half of the respondents indicated that their lack of technology strategy was a barrier. The bottom barriers are actually being underestimated."

The research also sought to uncover the collection rate that pharmacies were experiencing for services they were already offering. "Collection rates under 49% were pervasive across most of the services. On a positive note, when it asked if clinical services actually impacted revenue, 25% of respondents indicated moderate and significant increase in revenue related to those services and 74% combined indicated that their billing won’t meet their future needs at all," she said.

Beyond quantitative responses, out of 500 people, about 120 respondents gave free form responses. "We analyzed that in detail. There were many responses related to reimbursement. They spoke about their reimbursement challenges, along with regulatory and legal barriers. We wanted to hone in on a large number of responses that were related to a lack of resources: it wasn’t just staffing issues, it was really around all sorts of different types of resources and infrastructure. Think of technology, furnishings, privacy," she said. 

Lastly, Greefkes revealed that there also was an area where there was about 10% of those free form responses that were related to a resistance in an organization or a lack of support. "It was both aspirational in nature. People were focused on clinical service, they felt positive, and there was also skepticism. This is one area where it’s important to lean into that. It’s an underdiscussed area in terms of their alignment concept," she said. 

Ross took the discussion to the "reimbursement playbook," noting that the goal is to help set up the market in regards to what we’re seeing when it comes to the support of pharmacists to use their services under the billing benefit. "COVID put pressure into the Medicare Part B side and got it out there. We wish there were more adoption of getting more of the tail wind we got associated with initially. We feel there’s a lot of adoption. Regardless of the challenges, there is help on the way. Before that help gets put in place, we want to talk about alignment," he said.

Ross noted the following:

  • When we talk to our clients, we talk to individuals discussing how do they use some of the tools available. We really need to think about go to market and what that means, so we  always look at the alignment internally by the buy in and training and education. 
  • We start with the market access. As we think about going back to those legislative boundaries, we make sure we create less friction, being able to let the pharmacist operate at the top of their license and to stay ahead of credentialling requirements needed and that are so important. We need to document clinical episodes of care. Both clinical and financial clearance comes together. 
  • We really need to understand the evolution of the billing landscape. We're very used to going to primary care and specialists in understanding what post adjudication looks like. In the pharmacy world patients also are consumers. It’s a different experience walking into your pharmacy. As a proliferation of specialty pharmacy drugs come forward, and the need for the expansion of services in healthcare deserts, there’s a need to expand billing benefits and make sure friction is not there with an experience with the patients.
  • Engagement. We’re passionate about creating the patient pharmacy experience that is tied back to payor requirements so you understand those payor requirements so we can create and take the friction out of the processes to then support the patient in not just a clinical way, but in a consumer way.  We’re mindful of that.
  • Lastly, with the insights we have, the analytics, the reporting of this intelligence, the payor insights and behavior we’re able to leverage our data, even into an AI way to allow us to keep up with the payors as they continue to morph their behavior. It’s not one and done. You have to continue to improve the process. 

[Read more: OmniSYS, XiFin webinar focuses on how to take your pharmacy to the next level]

Keller proceeded to discuss the importance of clinical documentation, noting that pharmacist services are evolving across the marketplace. "With this evolution comes complexity from a documentation standpoint. Think about how do I provide documentation and bill services like other practitioners in the healthcare industry," she said.

Keller advised:

  • Use solutions like an EMR to have a record and bill. 
  • When it comes to ordering labs for patients, communication with the patient is critical, as well as being able to report lab reports to state authorities.
  • Pharmacies have the honor and pleasure to evolve services and need to think through these things. How do I have a solution that truly allows me to be a practitioner similar to the rest of the healthcare industry?
  • Some of the complexities and challenges as it relates to clinical service documentation varies by state. The type of services pharmacists can perform are different by states, and state protocols will be different. This can be difficult to mange. What are the protocols in my state, how do I keep up with new regulations? How do I partner with someone who can help me meet these requirements?
  • Interoperability. You’re no longer dealing with a single transaction in front of you. For example, if you have to send a patient out to get lab results. How am I going to order labs, get lab values back in my system? How can you communicate with others? You’ll need to communicate treatment plans to physicians, communicate test results to patients and report to government agencies.
  • Being able to exchange data with others will be an important piece of this. 
  • Comprehensive historical records are important. 

To view the entire webinar, click here.

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