My Journey

My journey through the world of long-term care pharmacy, as a Reimbursement pharmacy technician has been filled with waves of challenges and changes. From the onset of Medicare Part D to the complexities of short-cycle dispensing, the pharmacy reimbursement landscape has been anything but smooth. However, amidst these turbulent waters, Net-Rx^TM has been and continues to be a steadfast ally to its customers, providing the tools and support pharmacies need to navigate and thrive. I recognized the increase in my knowledge facilitated by the support of Net-Rx. This inspired me to become a support system for other pharmacies, and I am now continuing to advance my career with Net-Rx.

In this piece, you’ll learn about the challenges I faced with pharmacy reimbursement, from the initial waves created by Medicare Part D, including formulary changes and patient deductibles to those formed by the introduction of short-cycle. You’ll discover how Net-Rx, through its pharmacy management software solutions like EditRx which provides reports and dedicated analysts, played a crucial role in navigating these challenges. This story highlights the invaluable support and expertise provided by Net-Rx, which streamlines pharmacy workflows and helps ensure accurate reimbursements, efficient claim coding and processing, and ultimately contributed to my overall success in the pharmacy industry.

It was the initial waves created by Medicare Part D that led me to work at a long-term care pharmacy where I joined the reimbursement team.  Our days revolved around major billing practice changes, never ending prior authorization rejections, and phone calls with patients to discuss why donut holes¹ were in the pharmacy.  Once those waves settled, or at least felt more controlled, short cycle dispensing came crashing in and a brand-new set of waves was created. 

These waves were compounded by the swirling questions of correct pharmacy reimbursement and accurate claim coding. This is where Net-Rx dove into the water to assist.  While they didn’t eliminate the waves, they provided the resources to help face them head on and come out clean and dry on the other side. 

In my experience there is never enough time in a pharmacy reimbursement technician’s day to work through all the rejections, call for overrides, and verify all claims were submitted appropriately.  And this doesn’t even include the added stress of bills that must be sent out the first week of the month!  Time was short; double checking that AWPs had updated accurately was disrupting my workflow and didn’t fit into the schedule.  Nor did checking for losses on any of the of the prescriptions submitted to payers processed throughout the day. Into the waves came EditRx, Net-Rx’s life preserver, an enhanced claims editing service using proprietary analytics to identify claims that require a second look and, the support of a dedicated reimbursement analyst, it made detecting and correcting claims simpler and more efficient.  No more searching for inaccurate AWPs; if they were incorrect the EditRx reports told me.  No more wasted hours were spent reviewing claims for missing or inaccurate Dispense as Written (DAW), patient residence, or short cycle billing codes.  The claims were identified and organized for my review and verification that coding was done appropriately.  The EditRx reports streamlined my pharmacy workflow and helped identify educational opportunities on claim coding and submission for the pharmacy staff.

In addition to patient outcomes, as a Reimbursement Specialist I was also focused on the money; was that claim profitable or did we lose money? Can we increase our pharmacy reimbursement next time?  Was the dispense fee submitted correctly?  Does the reimbursement match the contracted rate?  There is that EditRx life preserver floating in from Net-Rx again.  Pharmacy reimbursement losses are inevitable, and Net-Rx identified those claims and categorized them so I could quickly jump to the wholesaler and purchase lower cost alternatives.  Helping to reduce loss is just the beginning of how Net-Rx worked to help maximize pharmacy profits.  As an added benefit of being an MHA member², the Contract Assure report verifies every claim submitted to an MHA LTC Network negotiated plan contract to ensure accurate reimbursement. During the review with our Net-Rx analyst, any claim not meeting the MHA negotiated rate was flagged. The analyst then engaged the MHA Network team to ensure the payer reviewed to confirm the proper actions for reimbursement in accordance with the MHA contract.  I really felt like somebody had my back, keeping me afloat through the rough waters and helped me navigate to ensure proper reimbursements.

Which leads me to what I consider the most valuable resource Net-Rx provides, the people.  If the EditRx reports are the life preservers in Net-Rx’s services, the analysts are the lighthouse.  Always there to shine a bright light on areas of concern and helping me to navigate the rough waters that are reimbursement in long-term care pharmacy.  If I couldn’t determine why reimbursement was low on a claim, they walked me through each step of the claim submission process until we found that one field or code that wasn’t populated quite right and celebrated my win after reprocessing and seeing the increased pharmacy reimbursement. I never felt that the Net-Rx analysts were part of a service the pharmacy was paying for; they felt like an essential resource to enable me to be efficient and improve our pharmacy workflow.

Yes, the data Net-Rx provided in the EditRx reports was a crucial part of the success of the pharmacy; and I agree with the saying “money talks.”  But the money-talking only matters if someone is listening.  And this is where the analyst comes in.  I had experience with other vendors in which reports were provided with similar data, or I was directed on how to pull the data myself, but that is where the support ended.  There was no assistance, explanation, or that feeling that someone had my back.  The Net-Rx analysts were my second set of eyes examining the reports and identifying those claim anomalies that can be so costly to the pharmacy, and so easily hidden.  I felt quite confident in my pharmacy reimbursement skills and ability to work the reports independently, but every conversation with my analyst identified something that I didn’t catch on my own; a subtle reminder that they truly are the experts.  Net-Rx was always ahead of the changes in the industry and provided guidance to work through the rough waters before they became rapids.  I knew I could rely on them to help find the answer, even if outside their area of expertise.   The analyst relationship exponentially increased that “someone has my back” feeling.  I was confident that with the support and guidance provided by Net-Rx I could continue to successfully navigate whatever waves the pharmacy world decided to throw at me next. 

Reflecting on my experiences, it was the unwavering support and expertise of the Net-Rx team that ultimately led me to join the company. The positive impact they had on my work, particularly through their tailored solutions and personal engagement, made it clear that Net-Rx was not just a vendor, but a partner in our success. This is why I decided to bring my experience full circle and contribute to the company that had played such a pivotal role in my professional journey.

¹The “patient donut hole,” also known as the “coverage gap,” is a term used in Medicare Part D prescription drug plans. It begins once you reach your plan’s initial coverage limit and ends when you spend a total out-of-pocket amount. For example, in 2018, the initial coverage limit was $3,750, and the out-of-pocket threshold was $5,000. During this gap, Part D enrollees received a discount on the total cost of their brand-name drugs, which included a discount paid by the drug manufacturer and an additional discount from the Medicare Part D plan.

²Net-Rx and Managed Health Care Associates, Inc. (MHA) share a collaborative relationship aimed at enhancing the operational efficiency and financial performance of pharmacies. Net-Rx provides advanced business analytics and support in billing practices and stabilizes data reporting for pharmacies during vendor relationship changes, while MHA offers a diverse portfolio of services including Group Purchasing, Managed Care, and Reimbursement Management. This partnership allows both organizations to leverage their expertise to support the complex needs of pharmacy healthcare providers and improve patient care.

Author

Jessica Hurban, CPhT-ADV
Associate Account Analyst
Joined Net-Rx in February 2024

Jessica is a Nationally Certified Advanced Pharmacy Technician with over 20 years of experience in retail and long-term care pharmacy, specializing in reimbursement and inventory management. As one of the first 1,000 technicians in the country to obtain the Advanced Pharmacy Technician Certification, Jessica furthered her education by earning a Bachelor of Science in Healthcare Administration.  Her extensive pharmacy experience and education led her to join Net-Rx as an Associate Account Analyst, where she provides guidance and education to ensure the execution of appropriate billing practices to maximize reimbursement. Jessica resides in Northwest Pennsylvania with her husband, daughter, and two dogs. In her free time, she enjoys traveling, exploring new cuisines, and cheering for the Pittsburgh Steelers.