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A Drug Trend report published in 2009 had predicted continued price increase among traditional branded and biotech drugs that lack generic competition. Now, further, CMS has reduced its Average Sales price (ASP) margin from 6 percent to 4 percent for non-pass-thorough. This has affected pharmacy reimbursement. However, there are certain other aspects of Pharmacy Billing that can affect reimbursement and thereby the Revenue Cycle Management (RCM) process if not well implemented.
1. Data Workflow:
Recognizing how the revenue cycle works in pharmacy is very essential. Procurement to Inventory, billing and reimbursement involves purchase of medications, their storage, and method of dispensing, how they are administered, way they are coded & billed, and finally reimbursed. If the drug is covered as a pharmacy benefit, or the payer needs that to be obtained via a specialty pharmacy as identified through patient-specific benefit verification, then here both the provider and the pharmacy are part of the reimbursement process. The physician writes a prescription and orders the drug. This is followed by the pharmacy that fills the order and issues the drug to the physician, CMHC, or hospital outpatient department. Here the pharmacy bills the insurance company for the drug. If any information is entered incorrectly into the pharmacy system in the initial phase of the cycle, errors can prove to be costly, impacting aspects of clinical and revenue cycle.
2. Procurement:
During this phase information is converted from purchased quantities and pricing to storage units of measure (UOM) and inventory costs. Manually entering the data is followed in most cases. UOM conversions, when data is uploaded from the wholesale distributor to the pharmacy system, are also checked and verified manually. Here too mistakes can lead to breakdown in the revenue cycle management (RCM) process.
3. The Charge master:
Critical & substantial revenue leakage can occur when separately reimbursable medications are either missing from or miscoded in the charge master. Conversion of pharmaceutical quantities is a must from purchased amounts to patient-administered amounts, and only then made billable. There is often a difference between dosage amounts required for patient use as from that purchased. Besides inventory, the clinician and pharmacist should convert dosage, strength, and delivery mechanism for each drug. Drug data must be correctly converted from the quantities residing in clinical systems into the payer-billable quantities appropriate for the financial system or charge master. The UOMs must be reconciled to avoid any under- or over-payments. More than often, missing or incorrect data in the charge master can result in negative financial consequences – denied claims, partial reimbursement, and compliance risks.
4. Linkages between Purchases & Billing:
Most hospitals have separate processes to order drugs, administer them, and process reimbursement. Without linkage between pharmacy expenditures for medications (i.e., spend data) and the charge master, ensuring proper charge capture and optimal reimbursement is a challenge. Besides hospitals should have automated tools to identify charge capture errors precisely, so as to pinpoint when and where their occurrence to decreasing revenue loss.
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Balcetis explains that when people are in shape, they are more likely to view an exercise as achievable. More important than fitness, however, was individuals’ motivation to exercise. Those who were motivated to exercise saw a finish line as closer, than those who were unmotivated.
In a second study, Balcetis experimented with how changing one’s perspective on an exercise, can help to make it seem more doable. Balcetis presented a finish line at the end of a moderate sized path. Her control group looked around their settings as they normally would, and then estimated how far away the finish line was. The experimental group was instructed to look directly at the finish line and to try to eliminate other objects in their point of view. The results: the group that kept their eyes on the prize estimated the finish line to be thirty percent closer than those in the control group.
Last, Balcetis examined how perspective can help directly improve ease and efficiency. She had subjects try a moderately difficult exercise of walking a fair distance with weights. Again, one group kept their eyes on the finish line, while the other group proceeded normally. Those who focused on the finish line, felt that the exercise was fifteen percent easier than those in the control group. The focused group also moved twenty-three percent faster.
So what do all these findings mean? The way we look at exercise can make a big difference in how hard it feels and how hard we work at it. As Balcetis says, “keeping your eyes on the prize, may be an additional strategy you can use to promote a healthy lifestyle.” Well any strategy that makes exercise seem easier and gets me working harder, is one I’m definitely down for.
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ED triage: Used daily to prioritize patient assessment and treatment in the emergency department during routine functioning. Priority is given to those most in need. Resources are not rationed. Inpatient triage: Applied day-to-day in a variety of medical settings, such as the ICU, medical imaging, surgery, and outpatient areas, to allocate scarce resources. Priority is given to those most in need based upon medical criteria. Resources are rarely rationed. Incident triage: Used in multiple casualty incidents such as bus accidents, fires, or airline accidents to prioritize the evacuation and treatment of patients. These events place significant stress on local resources but do not overwhelm them. Resources are rarely rationed, and most patients receive maximal treatment. Military triage: Used on the battlefield, modern military triage protocols most reflect the original concept of triage and include many of the same principles. Resources are rationed when their supply is threatened. Disaster triage: Used in mass casualty incidents that overwhelm local and regional healthcare systems. Disaster triage protocols both prioritize salvageable patients for treatment and ration resources to ensure the greatest good for the greatest number.
