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Pharmacy Revenue Mastery: Insights from Top-Performing Independent Pharmacies

The February 5th “Pharmacy Revenue Mastery” webinar featured valuable insights from Andy Silva, PharmD of Lino’s Pharmacy and Jesus (Isaiah) Cruz of Saenz Pharmacy, sharing their successful journeys in implementing medical billing services. Here’s a comprehensive recap of the key discussions.

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Starting the Medical Billing Journey

Both Saenz and Lino’s emphasized that many billable services were already being provided – the key was recognizing opportunities for reimbursement. As Andy Silva noted, “We were kind of already doing those types of things, but obviously we were doing them free of charge.” Their success came from studying available billing codes and understanding which services could be properly documented and billed.

Key Components for Success

The speakers shared that successful medical billing implementation requires comprehensive staff training and organization. At both pharmacies, all staff members receive basic medical billing training, while dedicated billing specialists manage claims processing. They stressed the importance of maintaining organized documentation systems for tracking claims and payments, with regular reconciliation of pending claims to ensure nothing falls through the cracks.

Documentation emerged as a critical factor in their success. Both pharmacies implement SOAP note templates for patient encounters and maintain thorough records of all billable services. They recommend keeping records for at least five years and establishing clear workflow processes for identifying billable opportunities.

Insurance verification has proven to be another crucial element. The pharmacies collect both pharmacy and medical insurance cards at intake and utilize insurance portals to verify coverage. Understanding the difference between HMO and PPO plans has helped them identify which payers consistently reimburse for services.

Most Successful Billing Codes

The pharmacies highlighted several codes that have proven successful in their practices.

• 99212: Office visits/patient assessments
• 99401: Preventative medicine counseling
• Specialized codes for CGM training and other specific services

The 99212 code for office visits and patient assessments, along with 99401 for preventative medicine counseling, have been particularly valuable. They’ve also found success with specialized codes for services like CGM training and other specific interventions.

Practical Workflow Integration

Both pharmacies developed efficient systems to identify billable opportunities within their regular workflow. They use visual indicators, such as blue papers, to help staff identify billable encounters, and have established clear communication protocols between pharmacists and billing staff. A next-day billing process for completed encounters ensures timely submission, while regular claim status monitoring helps maintain steady revenue flow.

Managing Expectations

The speakers emphasized several important points about medical billing reality. They stressed that not every consultation will be billable, and pharmacies should focus on quality over quantity in claims submission. Maintaining reasonable charging practices and continuing to provide services regardless of billing status are essential principles. They also noted the importance of being prepared for some claims to be rejected or require follow-up.

Looking Forward

The speakers emphasized the importance of pharmacies embracing their provider status and actively pursuing medical billing opportunities. As Andy noted, “Don’t wait – we want to be providers and be recognized providers, let’s go ahead and do so before the opportunity gets taken away and given to somebody else.” This proactive approach, combined with thorough documentation and organized workflows, has proven successful for both pharmacies in building sustainable medical billing practices.