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Dissecting the Complexity of Medical Billing for Clinical Services David Pope

Increase in the Patient’s Out-Of-Pocket Expenses

PharmD, CDE, Chief Pharmacy Officer XiFin Inc.

As the amounts billed for services increase, payors are shifting a larger portion of the financial responsibility to patients. This trend necessitates that pharmacies provide an accurate estimate of a patient’s out-of-pocket expenses based on yearto-date deductibles, co-pays, and coinsurance. Pharmacies also need to collect point-of-sale payment, issue patient statements, facilitate payments digitally and traditionally, track and reconcile payments, etc.

Good news! Pharmacists are billing for clinical services, including patient evaluation and management. Agreements for pharmacist-led services are now more prevalent, marking a pivotal moment in pharmacy practice. However, this brings new billing complexities, requiring detailed processing, rigorous reconciliation, and a focus on patient out-of-pocket expenses, necessitating robust claims processing solutions.

Managing patient payments effectively is essential to maintaining financial stability while ensuring a predictable and frictionless patient experience.

Multiple Services, One Claim With the expanding role of pharmacists comes the opportunity to deliver an “office visit,” which may include several services like consultation, tests, and prescribing. However, these encounters present specific medical billing challenges. Payors require pharmacies to consolidate office visit services into a single claim, with line-item details for each service. In turn, this creates unique technical challenges when using existing pharmacy management systems. Claim consolidation is standard in other healthcare environments, making it essential for pharmacies to adapt their technology and processes to be future-ready. Reconciliation and Denial Management by Service Line With the consolidated claims, Explanation of Benefits (EOBs) from payors are returned with detailed line items for each service. To manage this effectively, pharmacies need the ability to: reconcile payments at the service level, track payor payment/denial trends by service line, identify and address common denial reasons to improve the process, and stay up to date with changing payor requirements to ensure compliance. Effective denial and appeals management and streamlined reconciliation are crucial to maintaining accurate financial records and optimizing revenue cycles.

Claim Processing and Medical Billing Now Require a Financially-based Solution The complexity of medical billing requires comprehensive financial solutions. A future-ready Revenue Cycle Management (RCM) system with specialized services is essential. The ideal RCM solution should comply with GAAP/SOX standards and healthcare regulations, providing end-ofmonth financials, quarterly reports, expected reimbursement reconciliation, error processing summaries, a ledger-ready closing package, and thorough bank reconciliations. Putting a Revenue Cycle Management Strategy into Place Payor requirements have created an increasingly intricate medical billing landscape. A greater emphasis on detailed claims processing and patient financial responsibilities requires pharmacies to adopt a comprehensive financial system that helps them navigate the complexities of modern medical billing more effectively to ensure compliance, accuracy, and fiscal health.

Download the Executive’s Guide to Maximizing Pharmacy Revenue via Medical Billing now at XiFin.com/MedicalBillingGuide.