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Pharmacy Practice News • August 2022
Reimbursement Matters
6 Steps for Sending Clean Claims to Payors Hospital revenues are plummeting, so it’s time to take action!
T
he pressures wrought by COVID-19 on business are still with us, and it’s turning out to be a long road to recovery. Providers and health systems are looking for ways to navigate from financial uncertainty to financial viability, and are exploring ways to garner and protect earned revenue for 2022 and beyond. Pharmacy leaders must answer
the call for change and innovation and, like all leaders, need to be adaptive when confronted with unknowns or “dangers” to their routines. With these financial pressures, stress is real and often causes “threat rigidity”—a mindset that freezes innovation and a tendency to keep relying on what has worked in the past. It’s so
crucial to avoid these crisis missteps and address three common traps—narrow thinking, deferring to leaders who don’t embrace the need to respond proactively to these business pressures, and conformity. Fortunately, there are several techniques for recovering revenue, managing changing payment models, building
“Reimbursement Matters” is a tool for maintaining your health system’s fiscal health. Please email the author at bonniekirschenbaum@ gmail.com with suggestions on reimbursement issues that you would like to see covered.
Bonnie Kirschenbaum, MS, FASHP, FCSHP
A Reimbursement Lexicon APC, ambulatory payment classification; CMS, Centers for Medicare & Medicaid Services; EHR, electronic health record; HCPCS, Healthcare Common Procedure Coding System; LCD, local coverage determination; MAC, Medicare administrative contractor; NCD, national coverage determination; NDC, National Drug Code; OPPS, Outpatient Prospective Payment System; SI, status indicator
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better payor–provider relationships, and enhancing the patient financial experience. One of the first goals is focusing on the importance of getting claims right the first time and eliminating denials. It’s so much better to be right the first time instead of, sometimes fruitlessly, chasing denials. Complex payor rules and potential shifts in your payor mix— which are often due to massive unemployment—most likely have caused disruption in claims and payment. It’s now more critical than ever to maximize reimbursement from payors as soon and as smoothly as possible. This translates to strategies for managing denials and underpayments, improving up-front processes to prevent denial. None of this will proceed smoothly without an awareness of your facility’s revenue cycle shortcomings. For that, you’ll need to do an honest selfassessment. One overarching question: Do you lack the knowledge, experience and discipline necessary to register, bill and collect correctly? Are you confident that you’re getting patient data right the first time, recognizing that it’s the key to reducing payor denials? Without a clear answer and a plan for improvement, you may well be one of those hospitals or healthcare systems that leave millions of dollars on the table every year.
Processes to Ensure Reimbursement What can you do to ensure clean claims get to the payors in a timely fashion and your organization is receiving payment for expensive medications? Consider these six key steps:
1
Begin with an easy audit step. Determine which drugs are attached to miscellaneous HCPCS codes
