Intro
The practice of retail pharmacy today sits at an inflection point. Deteriorating PBM reimbursement continues to erode margins while increasing in complexity and lacking transparency. Once supportive partnerships with 340B-covered entities are now curtailed by drug manufacturer restrictions. Pharmacy team members’ ability to spend time with patients are hindered by staffing challenges and exacerbated by workplace conditions. We’re also staring at a financial meteor barreling toward our pharmacies with the DIR double-whammy during the first quarter of 2024.
Despite all these challenges, the profession of pharmacy continues to advance toward a brighter horizon. Over half of the states in the US have passed provider status legislation empowering pharmacists to perform cognitive services and receive compensation. Health insurance agencies accept billing for these services largely on the medical benefit rather than the pharmacy benefit. Whether a pharmacy got started with COVID-19 vaccines during the height of the pandemic or activated their provider status through statewide protocols, pharmacy owners are increasing patient satisfaction, employee satisfaction, and their bottom line by activating claiming their provider status and initiating clinical services. It starts with just one new activity. For those who haven’t yet started this journey, it’s not a question of if they can do this, it’s a matter of how they will transition their teams to capitalize on new revenue streams before it is too late.
The Need
Many pharmacies do not have a software solution to bill clinical services to the medical benefit or find existing solutions lacking robust capability and customer support. DocStation’s California pharmacy partner had a stack of unbilled vaccine administrations in 2021 and 2022 and needed a partner to help them get set up as a provider to bill multiple insurance companies in their region and process massive volumes of claims. They knew they could maximize vaccine reimbursement through the medical benefit by billing:
- Vaccine Product
- Vaccine Administration
- Vaccine Counseling
Solution
This California pharmacy chose DocStation as their partner because of the ease of getting started, low subscription fee, and expert support to navigate billing complexities. They got a kick start to their process through their DocStation collaboration by strategizing with a DocStation pharmacist. The DocStation team walked them through all the required elements for successful billing, including:
- Onboarding & training
- Enrollment & credentialing
- Clinical documentation
- Medical claims submission
- Claim status monitoring
With a significant backlog of billable opportunities, DocStation helped the pharmacy submit claims in bulk to help them win the race against timely filing deadlines. DocStation’s revenue cycle logic ensured that claims contained required information in standardized format, minimizing rejections and denials. The DocStation revenue cycle management team tracked every single claim and intervened when needed to resubmit corrections and maximize payment.
Outcome
Through this engagement, the pharmacy earned over $70,000 in net new revenue during their first year on DocStation.Their partnership with DocStation helped lay the foundation to bill any future clinical service to the medical benefit. DocStation’s electronic medical record enabled pharmacists to capture robust clinical documentation to support longitudinal patient management and support payer audit inquiries, if necessary.
The DocStation platform achieved over a 90% clean claims rate (i.e. approved & paid upon first submission), requiring no intervention or additional from from pharmacy staff.
