How do you identify and recover missing third-party payments and short paid or unpaid claims in the pharmacy? Approximately 95% of prescriptions are billed through a third-party payer (Number of Retail Prescription Drugs Filled at Pharmacies by Payer, 2019) for reimbursement. Payment to the pharmacy for any number of these claims can be short paid or missing which not only affects reconciliation, but negatively impacts your bottom line.

To help you monitor, identify, and recover short paid or missing payments, below are some best practice tips to help keep your pharmacy cashflow healthy.

Make sure your physical address and bank account information are up to date

These are two of the most common reasons a pharmacy may not receive payment. In order to reduce the chances of misdirected or delayed payments, ensure third-party payers and your pharmacy claims reconciliation vendor have the most up-to-date physical address and bank account information for your pharmacy. In addition, your pharmacy claims reconciliation vendor may be able to assist you with recovering missing checks or deposits.   

Compare payments received to remittance advices

Set aside time each week to compare the payments you received from third-party payers to the remittance advices.  If a check or deposit is missing, reach out to the third-party payer to confirm its whereabouts and ask to have the payment reissued if necessary.   

As a market leader in pharmacy reimbursement solutions, Net-Rx™ , provides its pharmacy customers with a Pending Remittance Advice Report. This report lists remittance advices for which the pharmacy has yet to receive payment, along with the amount due and from whom. 

What Is Pharmacy Reconciliation? Read more…

Monitor claims to identify unpaid and short paid claims

Review claims monthly to ensure that you received payment and you were paid at the adjudicated (promise-to-pay) amount. Even a small pharmacy can have hundreds of claims each week, making this a daunting task if done manually. However, it is important to monitor regularly to identify and respond to outstanding payments or claims paid at less than the adjudicated rate (otherwise known as short pay). A study performed by Net-Rx demonstrates that after 60 days over 4% of a pharmacy's receivables remain unpaid.

RecRx , a reconciliation service offered by Net-Rx, provides pharmacies with an Aging Report that lists all short paid and unpaid claims over a user-defined period, regardless of the third-party payer, age, and amount. Pharmacies can  automatically add the aged unpaid and short paid claims to a pre-formatted payer follow-up letter, which the pharmacy  can send to payers by email, fax, or snail mail to request payment of these unpaid claims. The aging report also includes information regarding previously paid claims that have been subject to takebacks by third-party payers allowing the pharmacy staff to verify if they were subject to an audit or if there was some other reason given by the payer so they can classify them appropriately. 

Follow-up with payers

Pharmacies are busy and may not have time to devote to monitoring unpaid and short paid claims or following up with the payers for recovery. Net-Rx has an add-on service to RecRx, called Aging Assist, which assists pharmacies in managing their aging by:

• providing insights into why the claims are reporting in aging
• determining the best course of action to clean up any that do not require payer follow-up and assisting in that process
• facilitating follow-up activities directly with payers in an effort to obtain reimbursement for unpaid claims on behalf of the pharmacy  

Even the most well intentioned and detailed pharmacy may experience challenges in identifying missing or short paid claims. Following these tips is a great place to start. Leveraging solutions and support from Net-Rx can help streamline and automate the process to recover payments and save time for staff, helping your cash flow and efficiency.

Pharmacies can rely on Net-Rx for superior support, actionable insights, and proven results.   Our customers have access to pharmacy reimbursement trained analysts who can provide guidance to help you correct errors and attempt to recover otherwise lost revenue.

At Net-Rx, we remain steadfast in our core values of commitment and dependability. Our market-leading solutions help customers maximize opportunities, minimize risk, reduce operational costs, and increase their profits. Contact us to learn more about how Net-Rx can help you.

©2023 Managed Health Care Associates, Inc.

Read other insightful articles from Net-Rx covering topics that matter to your pharmacy.

By Kathleen Skokan, Manager, Net-Rx  

Kathleen has started as an Reconciliation Analyst at Net-Rx in 2005 and is now a Manager on the Customer Success team.  Working in a pharmacy many years ago as a technician provided Kathleen with a unique perspective of the challenges our members face in billing and reimbursement from third party payers and helped frame her commitment to find workable solutions to those challenges.  As a Manager she is privileged to work with a team of knowledgeable individuals who care deeply about the success of our members which continues to be her source of motivation. She is a west coast girl from Portland, Oregon.  She loves the beautiful Cascade Mountains, the Oregon Coast and spending time with her very large family.  

References

Number of Retail Prescription Drugs Filled at Pharmacies by Payer . (2019). Retrieved from KFF.org: https://www.kff.org/health-costs/state-indicator/total-retail-rx-drugs/?dataView=1&currentTimeframe=0&selectedDistributions=commercial--medicare--medicaid&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D