Like any other medical billing in healthcare, pharmacy billing has never been easy because of its complex procedures and frequent regulation updates. For clinical services provided by a pharmacist, the billing format is different from that of a provider which makes it all the more complicated.
Here are a few challenges commonly faced in pharmacy billing services
Staff issues –
- There might be a case of the roles and responsibilities not being identified properly during billing. Sometimes, pharmacies may also settle for inexperienced billers which causes issues like incorrect modifier usage, improper billing calculations, etc.
- Another major challenge can be when the staff isn’t aware of the updates in the billing system. The staff should always have accessible resources with updated information about the various drugs and their codes.
- The staff might not always be aware of the maximum dosage requirements of each drug.
- There are only certain drugs, injections, and therapies that are covered under insurance. The staff of the pharmacy needs to assess them correctly if it is worth including or excluding the services during billing.
- Shortage of staff may lead to problems like wastage of time and energy, especially during handling critical cases.
Customer issues –
- There might be missing or inadequate information on the allergies caused by different drugs in the system. The pharmacy vigilance department keeps sending updated information time-to-time. This can be a problem in customer service and loss of reputation.
- There may be many challenges in the process leading to poor quality of customer services, hence becoming a problem in building customer relations.
- Customer service can be delayed if the staff takes time to look for the codes while billing. Hence, the focus on customer service reduces.
System issues –
- Your billing system may not be updated with the latest technology, which can cause hindrance in patient billing.
- The billing system may not be updated with all the latest government rules and codes for various drugs. Your staff also needs to be given training at the same time, so that they can also adapt to the new rules.
- The system you use may not be flexible. Systems may not process vaccine claims or medical benefits, which may cause an issue. In this case, staff may submit claims resulting in a waste of time because of claim denials later.
- Your system may not be scalable, especially in cases of in-house billing systems. A wrong Charge Description Master (CDM) may result in fines, claim denials, and underpayment.
This is one of the most common challenges faced by pharmacies. When old accounts exceed 90 days, they get ignored. The money owed to providers may go on increasing and there isn’t any specific strategy to deal with it. Your huge accounts may need attention and new strategies to recover all the outstanding accounts.
Incorrect payments may occur due to errors while submitting data and can lead to wrong A/R calculations. It can later cause a huge issue on budget planning and revenue.
Inadequate document codes
- There may not be adequate document codes for all the drugs in the system and hence can create a major problem while billing.
- Inadequate information, missing medical records, or lack of updated drug codes in the system can cause frequent claim denials.
Last but not the least, frequent errors like these can invite the attention of auditors and may have major implications like huge fines or cancellation of contracts.
Some tips to ensure smooth functioning
- Maintain centralized and automated IT systems to avoid duplication and errors.
- Keep updating your system and staff with up-to-date information on drug codes and government rules.
- Try integrating your inventory management with your billing system.
It is extremely important for pharmacists to stay up to date with the Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) to be able to bill for medical benefits availed by patients for their insurance plans.
Although these challenges can be overcome by streamlining the whole process, pharmacies may prefer outsourcing pharmacy billing services.
If you’re looking to outsource to a trusted company, 24/7 Medical Billing Services provide end-to-end services at affordable costs for your pharmacy. We ensure to take care of all your needs so that you can focus more on excelling in customer service.
Read more: 10 Common Blunders Of Pharmacy Billing