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Choosing a career path in long-term care (LTC) pharmacy, especially as an owner-operator, is challenging yet rewarding for those who enter this specific segment of the profession. Often, an LTC pharmacist is also the owner-operator of their LTC pharmacy business. That means doing it all. Owner-operators wear many hats like CEO, COO, CFO, and HR, which builds upon the responsibilities already faced with caring for a long-term care patient population.
Do you find yourself wondering when will you get paid for third-party prescription claims that have been recently adjudicated?  Or how long it takes to receive payment from the Pharmacy Benefit Manager (PBM)?  Does one PBM pay faster than another?  Do your payments seem to be taking longer than normal to arrive?  As a pharmacy owner, knowing when you will be paid provides an advantage to making strategic decisions, budget forecasting, and making investments to grow your business. 
Do you know when you can expect payment from third party payors for prescription claims? According to a Net-Rx study of 2,187 NCPDP’s over a 6-month period, 86.1% of claims are paid within 15 to 30 days after the promise to pay was issued (Peterkin, 2021). Whether the funds are received by paper check or electronically deposited into the pharmacy’s bank account, they are usually delivered along with an explanation about the payment.
Mastering short-cycle rules can be challenging and confusing. Coding practices can negatively impact your reimbursements if not followed according to Centers for Medicare and Medicaid Services (CMS) short-cycling guidelines. To help avoid the headaches that may accompany common pitfalls, like under-reimbursements due to improper coding, it is important to identify the issues and have the knowledge to remediate them to maximize reimbursements and prevent audits. In this article, you will learn the basics of appropriate coding, how to identify exceptions to short-cycling rules, and how coding ensures transparent communication with the plan.
Pharmacy managers are faced with managing the delicate balancing act between collecting maximum reimbursements from third-party payers and offering competitive drug pricing to patients who do not have insurance. There are several factors that pharmacies can consider when determining their Usual and Customary pricing strategy.
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