The pharmacy owner faced multiple billing and reimbursement challenges, particularly with Medicaid and Anthem Blue Cross Blue Shield (BCBS). Initially, over 400 Medicaid claims were submitted but went unpaid due to issues with the pharmacy's Medicaid enrollment. Once DocStation identified the root cause, the team worked closely with the pharmacy to resolve these enrollment barriers and enable successful claim submission.
However, even after correcting enrollment, claims continued to be denied due to billing inaccuracies. DocStation provided hands-on support to correct these issues, which included improper CPT codes, place of service errors, and incorrect taxonomy selections. With DocStation's guidance, the pharmacy rebilled claims correctly, leading to successful reimbursement.
In the last two months, substantial progress was made. All previously denied Medicaid claims were rebilled and are now getting paid. DocStation also intervened on behalf of the pharmacy to resolve outstanding issues with Anthem BCBS, ensuring claims were properly processed and reimbursed.
Key actions taken by DocStation:
- Identified and corrected Medicaid enrollment issues, enabling claims to be submitted.
- Provided training on accurate CPT codes, place of service, and taxonomy use.
- Guided the pharmacy in preparing and submitting corrected claims to meet payer requirements.
- Helped rebill over 400 Medicaid claims, resulting in successful payments.
- Reached out to Anthem BCBS to resolve claim issues and ensure timely reimbursement.
Full resolution required Jay to take an active role in understanding the underlying contracting issues with Medicaid and BCBS. Although he initially had the option to handle this independently, he decided to partner with ProviderCSAO for credentialing support. Like many providers, he encountered common challenges with payer credentialing, but with ProviderCSAO's assistance, he was ultimately successful in securing the necessary contracts.
While DocStation delivered education and insights grounded in data, Jay recognized the importance of developing a deeper understanding of medical billing—a crucial component of long-term success. He initially expressed frustration about his lack of clarity around his contracts and enrollments, particularly regarding the differences in reimbursement rates when billing through Medical Mode (MM), where the rendering provider follows the physician fee schedule. However, Jay quickly shifted his approach, becoming more engaged by asking informed questions, actively managing his DocStation dashboard, and refining his pharmacy's billing workflow.
It's important to emphasize that Jay led much of this effort in collaboration with DocStation. The partnership resulted in significantly improved billing accuracy, increased reimbursement rates, and a stronger overall revenue cycle for the pharmacy.
