Simplifying Medicare: The Distinction Between Medicare’s Offerings for Medications and Pharmaceutical Care

Few medical professionals wear more hats than a pharmacist.

As the face of healthcare continues to evolve, the work of a pharmacist has greatly shifted. Pharmacists are integral to patient care, providing critical health advice, managing complex medication regimens and navigating the intricacies of insurance plans.

One of the challenging aspects of a pharmacist’s role is understanding an insurance company’s preferred method for billing products and services. From dependent subscriber IDs to products that no longer bill to the pharmacy benefit, sometimes the adjudication process is by trial and error. Medicare-aged patients add a layer of complexity because of the differences between Medicare plans and payer behavior within them.

Medicare—one of the most complex and critical components of the healthcare system—presents unique challenges for patients and healthcare professionals alike.

A pharmacist who is well-versed in the various plans is an enormous asset to their patients and plays a critical role in ensuring the financial health of their organization.

Let’s begin by looking at Part C and Part D, exploring their key features, benefits, and how they differ.

Medicare Advantage Plans: An Overview

Medicare Advantage, also known as Medicare Part C, is an alternative to original Medicare.

Medicare Advantage plans are offered by private insurance companies approved by Medicare.

These plans bundle together the benefits of Medicare Part A (hospital insurance) and Medicare Part B (outpatient medical insurance) and often include additional benefits such as prescription drug coverage (Medicare Part D), dental, vision, and hearing services.

Medicare Advantage plans cover all the inpatient and outpatient services that Medicare Part A and Part B cover, with the exception of clinical trials and hospice services. (Hospice will still be covered by original Medicare if needed.)

Some of the medically necessary services covered by Medicare Advantage plans include:

Additionally, many Medicare Advantage plans include prescription drug coverage. For a patient to get prescription drug coverage with original Medicare, they would need to purchase a separate prescription drug plan and pay an additional premium.

What are the biggest benefits of Medicare Advantage plans?

A common question patients may ask their local pharmacist as they contemplate their Medicare eligibility is:

“What exactly is a Medicare Advantage Plan?”

This question is understandable. Medicare is confusing, particularly for older patients who may already be struggling with the complexities of their healthcare needs and the endless decisions they have to make.

A well-informed healthcare provider is instrumental in helping these individuals navigate their options and needs. There are even brokers in this space to assist Medicare-eligible individuals with navigation og their options.

Here are some of the biggest healthcare benefits that a Medicare Advantage Plan can bring to patients:

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  Medicare Advantage is all about convenience:

  These plans bundle hospital, medical, and often prescription drug coverage into one plan, simplifying the management of healthcare benefits.

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  Medicare Advantage often offers cost savings:

  Most Medicare Advantage plans have lower out-of-pocket costs compared to original Medicare, and some plans offer $0 premiums.

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  Medicare Advantage gives extra benefits:

  Some plans offer additional benefits such as fitness programs, over-the-counter drug allowances, and transportation to medical appointments.

There are also some drawbacks to Medicare Advantage that your patients should know:

• Medicare Advantage may have provider restrictions: Medicare Advantage plans typically require you to use a network of providers and care locations. Going outside the network may result in higher costs or no coverage at all.
• Medicare Advantage often needs prior authorizations: Some services may require prior authorization, which can delay care.
• Medicare Advantage Plans can be inconsistent in their offerings: Benefits and costs can vary widely between plans and regions, making it important to compare options carefully.

Understanding the strengths and drawbacks of Medicare Advantage plans can help pharmacists guide their patients as they work to make informed decisions for their healthcare needs.

Medicare Part D Plans: An Overview

Medicare Part D is the prescription drug coverage program that helps subsidize the cost of prescription medications for Medicare beneficiaries. Like Medicare Advantage, it’s offered by private health insurance companies.

Beneficiaries pay a monthly premium, which can vary based on the plan and coverage options chosen. Not only that, but cost-sharing elements such as annual deductibles, copays, the dreaded “donut hole”, or coinsurance may apply.

Medicare Part D plans are specifically designed to cover outpatient prescription drugs.

Beneficiaries can obtain Medicare prescription drug coverage in two main ways:

Stand-Alone Prescription Drug Plans (PDPs):

These plans cover only prescription drugs and are typically used to supplement original Medicare (Part A and Part B).

Medicare Advantage Plans with Integrated Part D Coverage (MAPDs):

These plans bundle prescription drug coverage with other medical benefits, providing a comprehensive healthcare package.

According to the Centers for Medicare/Medicaid Services website, more than 50 million Medicare beneficiaries had prescription drug coverage through Medicare Part D in 2022.

The total Part D beneficiary count is split between those who have Part D coverage in conjunction with a Medicare Advantage plan and those who have stand-alone Part D prescription drug plans, most of which are purchased to supplement Original Medicare.

Pharmacists and other providers need to understand how Medicare Part D works for the millions of Americans who are enrolled in the program today.

Leaning on Trusted Advisors: How Pharmacists Can Help Optimize Patient Selection in the Right Medicare Program

Pharmacists play a crucial role in the healthcare system, often serving as the most accessible healthcare providers for older patients.

Many seniors visit their pharmacists more frequently than any other healthcare professional, making pharmacists uniquely positioned to assist in navigating Medicare options.

By getting to know patients through their frequent interactions, pharmacists can provide personalized guidance and support for their most vulnerable group of patients, ensuring that they select the Medicare benefits that best meet their needs.

Here are some ways that a pharmacist can be the most trusted ally for a patient trying to navigate the Medicare system:

• Simplify the information: Break down complex Medicare information into easy-to-understand terms. Use visual aids and pamphlets to help explain the differences between plans.
• Incorporate informational sessions during billable encounters: During workshops or one-on-one counseling sessions, pharmacists can educate patients about their Medicare and health coverage options.
• Utilize technology: Use digital tools and resources to provide up-to-date information and comparisons of different Medicare plans.
• Follow-up: Regularly check in with patients to ensure they understand their coverage and address any questions or concerns they may have.

By actively engaging with patients and providing expert guidance, pharmacists can play a pivotal role in optimizing patient utilization in the Medicare program best for them, ultimately enhancing patient care and health outcomes.

Know Your Numbers: Maximize Medicare Reimbursements to Ensure Your Pharmacy’s Financial Health

While it is important to help patients navigate their Medicare needs, pharmacists also need to understand Medicare’s intricacies to address common billing challenges.

A pharmacy’s financial health is vital just like the patients’ physical health. Together we are important pillars in holding up and enriching our communities.

Accurate billing and documentation are essential to avoid denied claims and ensure timely reimbursements.

Let’s look at some of the best practices for accurate billing and documentation:

Some of the Key Benefits of Enrolling in a Medicare Part C (Medicare Advantage) Plan:

• Comprehensive documentation: Ensure all patient encounters are thoroughly documented, including symptoms, diagnoses, treatments, and outcomes. Use clear, concise language and avoid vague terms.
• Stay updated on Medicare guidelines: Regularly review and adhere to the latest Medicare billing guidelines and documentation requirements to avoid errors and potential audits.
• Detailed coding: Use precise coding for all services provided. Familiarize yourself with the Current Procedural Terminology (CPT) codes or partner with a company like DocStation and ensure codes  accurately reflect the services rendered.

• Regular self-audits: Conduct periodic self-audits to identify and correct any billing errors before they lead to denied claims or audits.

The Best Tools and Resources for Streamlining Billing Processes

In order to make sure you are capturing every dollar that is owed to your pharmacy from Medicare, you’ll want to have certain tools in place to help you do this.

Medicare, as mentioned, is a complex system and it’s easy for revenue to be missed or overlooked due to billing errors or incomplete documentation.

To ensure you capture every dollar owed to your pharmacy from Medicare, consider implementing the following tools and practices:

By adopting these best practices and utilizing available tools, pharmacists can optimize their billing processes, reduce errors, and ensure their pharmacy’s financial health remains robust.

This proactive approach not only benefits your pharmacy but will also enhance your patient care by ensuring that all services are accurately documented and reimbursed.

Better Patient Care, Better Financial Management: DocStation for the Win

You became a pharmacist because you want to spend your days caring for patients, not thinking about payments.

From ensuring accurate medication dispensing to providing essential health advice, your focus should be on improving patient outcomes.

DocStation is the all-in-one platform that can help you do just that.

DocStation is the only solution you need, aside from a dispensing system, for your clinical practice.

Our comprehensive suite of services empower pharmacies to provide exceptional patient care, submit medical claims efficiently, and participate in payer-sponsored programs—all on one easy-to-use platform.

With DocStation, pharmacies can care for patients, bill for all services, and engage in payer-sponsored programs in less time and with more accuracy than ever before.

With DocStation, you can get back to providing the care you want, get paid what you deserve, and practice through the entire scope of your license.

Reach out today and join the DocStation movement.