3 RCM Challenges for Specialty Pharmacy in 2021

It’s estimated that 10,000 Baby Boomers are turning 65 each day, leaving pharmacies to absorb and deal with the challenges of providing prescriptive services for a “graying America” while reimbursement continues to shrink.  Adding an exponential layer of complexity to this is the fact that people are living much longer, and benefitting from advanced specialty care that often relies on specialty pharmaceuticals, such as viscosupplementation for arthritis and joint treatment.

More than ever, it’s critical to be positioned to thrive in this environment which means embracing the technology and the business models that bring the most organizational benefit.  Rethinking where to focus expertise is one way to meet the challenges as volume continues to expand.  One option to evaluate is engaging a third-party partner to manage the revenue cycle management (RCM) component of your business which allows you to focus on patient care and regulatory compliance.

As the Centers for Medicare and Medicaid Services (CMS) policies on reimbursement get tighter and more restrictive, specialty pharmacies need to be proactive in restructuring their RCM to ensure that claims are handled timely with little error and money is collected quickly.  By considering a third-party partner that is technologically advanced and able to provide billing and collection services 24/7, you ensure a healthy bottom line capable of funding the expansion necessary with future growth.  Let’s look at three areas where a partner could improve accuracy and billing procedures.

Accurate New Admission Entry

High volume prescription processing inherent in specialty pharmacies requires the ability to present quick, clean orders that are on time and accurate.  Additionally, each prescription must meet regulatory and procedural guidelines so that it can be adequately tracked and billed.

A third-party partner would access the new patient documents and incoming orders and enter them into your system using the rules and protocols identified by your pharmacy. Your orders would be evaluated for priority in real-time, and processed according to patient need and pharmacy delivery run times. And with a 24/7 workflow, prescriptions can be processed even after hours.

Prior Authorizations for Specialty Prescriptions

As is the case in the entire healthcare industry, prior authorizations are handled manually by most entities.  This means unproductive time sitting on hold or faxing approvals that can be better handled by your third-party partner to free up your staff to manage more pharmacy-specific tasks.

If it’s determined that prior authorization is needed, your partner team would be able to process and submit the approval request electronically 24/7, as well as follow up on the status and notify your pharmacy team once the approval has been secured.  With quick turnaround times, prescriptions can be processed efficiently, and the patient’s needs are met appropriately.

Managing the Billing Volume

From performing account set-up and insurance verification to managing the daily volumes of workflow, utilizing a billing partner would increase your efficiency and improve your reimbursement.  Additionally, this would have the added benefit of allowing your staff to absorb the growing demands of increased business.

Without a doubt, specialty pharmacies have a crucial and ever-expanding role in the healthcare of our aging population.  The sheer number of new patients being anticipated in the future can be overwhelming.  Now is the time to evaluate the efficiencies and cost savings brought by a third-party partner as the needs continue to grow. Contact us to discuss how a third-party partner can alleviate your billing challenges.

About the Author

Infinx Healthcare provides innovative and scalable payment lifecycle solutions for healthcare practices. Combining an intelligent, cloud-based platform driven by AI with our trained and certified coding and billing specialists, we help clients realize revenue, enabling them to shift focus from administrative details to billable patient care.

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