Reduce Touchpoints of LTC Pharmacy Claims for a Smoother Adjudication Process

In the rapidly evolving healthcare delivery system, it is increasingly difficult for any healthcare business within the continuum of care to succeed at improving patient outcomes while reducing costs. The prescription claims process is one aspect that significantly contributes to unnecessary, and avoidable, costs. When a prescription is dispensed, as the pharmacy team, we/you bill that claim to an insurance provider on behalf of the patient. Sounds simple, right? For a Long-term care (LTC) pharmacy, the additional requirements to properly service this high touch population can compound the opportunity for human error within the billing process.

LTC pharmacies provide essential services to the aging population in senior living communities as well as to patients with challenging disease states, disabilities, and in behavioral or memory care settings. These populations often have complex medical conditions, with three or more chronic diseases¹ requiring between an average of nine to thirteen prescriptions per patient per month² compared to four prescriptions per patient for the average American³.

Given the number of prescriptions per patient and the vast array of services provided, LTC pharmacies generally submit a higher volume of claims to insurance providers in a more recurring cadence than the average walk-in pharmacy. In fact, approximately eighty-five million Medicare Part D claims are submitted every year through the MHA Long-Term Care Pharmacy Network. Add to that, claims submitted to other types of insurance including state Medicaid, commercial, and Medicare A claims that come with their own sets of coding requirements. This higher number of claims combined with complex LTC specific billing and coding rules, opens the door to added opportunities for rejections or billing mistakes that can result in lower reimbursement and retrospective payer reviews with takebacks. The fact that these prescriptions are often recurring refills, can add to the strain because one error can replicate across dozens of subsequent claims.

It is practically impossible to achieve an error free claims submission rate of 100%.  In fact, a certain percentage of claims (some pharmacies experience higher rates than others) are ultimately rejected by the payer even though services have been provided. So, finding a proven solution that helps mitigate error prone submissions and ensures claims are paid appropriately the first time is critical to maintaining your bottom line and optimizing your workflow.  Pharmacies should assess their coding risk to understand their individual situation, including staff training levels, most common root causes for rejections, percentage of re-submissions, billing error rates, and more.

A claim may be rejected for various reasons - incorrect drug selection, missing submission clarification codes, mismatched quantity, or broken packages, etc. But whatever the reason, it’s important to reduce error rates in a busy pharmacy. A rejected claim here and there may not seem like a big deal, especially since the pharmacy biller can resubmit the claim if the error is later identified. However, each correction costs the team precious time to re-work the claim. And each subsequent claim submission incurs additional transaction fees from both the switch provider and the payer, so when there are multiple submissions for one claim, the time and fees can add up and result in a significant increase in costs.

Of course, not all claims get rejected. Many claims are paid, but at a rate lower than the contracted reimbursement rate. In these instances, the pharmacy may never know they were under-reimbursed. To identify this missing revenue, they would need to review their claims after the fact, find the errors, make corrections, and then resubmit the claim to obtain the correct contracted rate. Not all pharmacies have the staff to perform this function on a regular basis and for those that do, this process delays the final payment, by weeks if not months, slowing down the time it takes to get paid and negatively impacting cashflow for the business. This is why it is critical for every LTC pharmacy owner to have a system in place to catch and correct errors in claims before they are submitted.

Work Smarter, Not Harder

At Net-Rx, we recognize that LTC pharmacies face unique challenges as they strive to meet the needs of the patients and facilities they support, while also successfully managing their business. Our goal is to help LTC pharmacies get claims submissions right the first time, resulting in increased cash flow and improved workflow efficiencies as well as peace of mind knowing the dollars earned are paid at the contracted reimbursement rate and have reduced exposure to retrospective reviews and takebacks.

That’s why we developed Script-IQ^®, a pre-edit component that complements our reimbursement suite of services. Script-IQ is a solution custom-designed specifically for LTC pharmacies to transform the claim quality checking process with the complexity of LTC billing and coding in mind. Script-IQ integrates directly with a pharmacy’s dispensing software and enables claim evaluation and correction to occur before the transaction hits the switching system and payer adjudication process. Resolving issues before transmitting the claim helps reduce the time spent on submissions and resubmissions, lessens transaction fees, and maximizes reimbursement.

Read more about the Benefits of a Pre and Post Edit Solution

While no system, human or electronic, is 100% error-free, implementing a solution that is dedicated to reducing mistakes and subsequent touchpoints of claims during the billing process can provide workflow efficiencies along with peace of mind. Script-IQ runs behind the scenes keeping the claims process running smoothly, preventing common errors, and providing real time feedback to your billing team to increase knowledge of best practices. All of this equates to saved time, knowledgeable & confident employees, reduced costs, increased revenue, increased cash flow, and protection of earned dollars from takebacks.

Start Cleaning Your Claims Right from the Start

If you are an LTC Pharmacy that has not examined the efficiency of your reimbursements lately, you may find leaks that are materially impacting your prescription income. Small and steady drips can ruin even the most stable foundation. It is critical for every LTC pharmacy business owner to have a system in place to catch and correct claim errors before they are submitted.  

Request a free Reimbursement Readiness Assessment to learn more about how Net-Rx helps Long-Term Care Pharmacies stop the leaks and protect prescription income.

 

References

1. 2019 MHA Independent Long-Term Care Member Study
2. Managing the Challenges of Long-Term Care Pharmacies for At Home Patients. https://www.pharmacytimes.com/view/managing-the-challenges-of-long-term-care-pharmacies-for-at-home-patients
3. The Differences Between an LTC Pharmacy and a Retail Pharmacy. https://www.macspharmacy.com/blog/the-differences-between-an-ltc-pharmacy-and-a-retail-pharmacy/