Improving your pharmacy claims processing workflow: A biller’s guide

Pharmacy claims can be complicated and difficult to navigate with their various rules, coverage levels, and plan allowances. Thus, the efficiency of your pharmacy claims processing workflow must be optimized to keep pace with ever-changing payer rules.

Here are three ways you can improve your pharmacy claims management workflow.

Enhance your prior authorizations

Pharmacy claims are usually affected by manual prior authorizations. When the pharmacy receives a prescription from a provider, the first step is determining whether prior authorization is required to ensure the medication meets payer’s coverage levels for the individualized benefit allowances. Receipt of prescription is vital to medical pharmacy claims management, significantly important because one in four patients now experience delays in starting medications due to prior authorizations.

Confirm patient data

For full reimbursement, pharmacies must gather complete and accurate patient data, including name, address, and date of birth. This step is also when insurance eligibility is verified. When done manually, this is a time-consuming, error-prone process, but automated patient access and eligibility verification solutions can enhance efficiency.

These solutions help reduce errors and denials by validating claims data before the claim is submitted for payment. They streamline the data verifications that would otherwise be a tedious workflow, flagging missing or inaccurate information from the claim to be corrected before it causes delays in the revenue cycle.

Additionally, pharmacy management systems like Inovalon’s ScriptMed^® Specialty provide checklists for pharmacists to create claims, prepare orders, and update inventory as prescriptions are filled.

Improve your denial management

The pharmacy claims adjudication process assesses the accuracy and validity of a claim and can have three results:

• • Accepted – the claim moves on as intended, ending with payer reimbursement
  • Denied or declined – the claim is sent back to the provider and often requires additional documentation to resubmit
  • Reversed – if a medication does not go out as intended, this determination logs the result for benefit and inventory purposes

Claims denials are by far the most common cause of delays in the pharmacy claims processing workflow. Aside from the administrative hassle, denials make it longer to get medication into the hands of the patient. While there are various reasons for denials, there are a few clear steps you can take to better avoid denials.

Such opportunities may include:

• • Identifying your most common denial reason codes, to notice workflow patterns that can be corrected going forward
  • Conducting ongoing staff training on claims management best practices
  • Encouraging regular training on your claims management software, to ensure your team is best utilizing the technology you have in place

Additionally, as volume increases, more resources may be needed. For example, a certified pharmacy technician can move tasks along, complete reporting, and help with prescription processing and managing payer policy and regulatory changes. Such a dedicated resource not only saves time, but can also help identify further opportunities to improve your pharmacy claims workflow.

Improve your pharmacy claims processing workflow with Inovalon

Inovalon’s RCM solutions serve providers across healthcare – from acute and post-acute settings to pharmacies and other specialists – to provide comprehensive data and interoperability that is often lacking for many organizations’ revenue cycles. Our RCM solutions simplify every step of the pharmacy claims processing workflow in a single system, with a single sign-on, so you can reclaim your day.

Inovalon and design^®, Inovalon^®, and ScriptMed^® are trademarks of Inovalon, Inc.