Oncology Rounds

Your secret weapon for unlocking outpatient drug reimbursements? Pharmacists.

by Gina Lohr and Jessica Preston

As drug costs grow, health systems must ensure they receive adequate reimbursement for outpatient drugs. A single regimen of chemotherapy can cost tens of thousands of dollars, so every unpaid insurance claim cuts into system margins.

Use these resources to optimize infusion center business and operations

However, ensuring reimbursement for claims is complex. Often, payers require specific clinical information to verify a treatment's appropriateness. Traditional billing departments often lack the clinical expertise to appeal and convert drug reimbursement denials.

Why pharmacists are the ideal partner for full reimbursement capture

A pharmacist's skills and expertise are crucial for getting full drug reimbursement. Here are three key reasons pharmacists are invaluable members of the revenue integrity team:

  1. Clinical expertise: Pharmacists bring deep clinical expertise and specific drug knowledge. This proficiency enables them to quickly identify the cause of a denial and pull together needed information to craft an appeal.

  2. Collaboration: In their day-to-day work, pharmacists communicate with a variety of stakeholders, from patients to providers to insurance companies. Thus, pharmacists are often highly skilled at building relationships and working across disciplines. This expertise is critical for revenue cycle management, where multiple departments often need to collaborate on any given appeal.

  3. Persistence: Successfully appealing a denied insurance claim involves a lot of back and forth, often over the course of several months. Here, pharmacists can leverage their management and patient advocacy skills to effectively overturn denials.

UNC's Pharmacy Revenue Integrity team appeals denials, advocates for Medicare coverage changes

In a recent article, UNC Health Care pharmacy leaders explained how they created a pharmacist-led Pharmacy Revenue Integrity team to capitalize on the value of pharmacists in reviewing and appealing drug reimbursement denials. Early results have been promising. Pharmacists' collaborative efforts have driven front-end change to the revenue cycle processes and their clinical expertise and persistence led to sizeable revenue from appeals. In one instance, the team recovered $200,000 in reimbursements for a single cancer patient.

Additionally, the team successfully appealed to have their regional Medicare coverage determination guidelines amended to match the most up-to-date cancer care guidance. This change ensured that UNC could continue to provide cutting-edge cancer care without risk of Medicare denials.

6 ways your pharmacist can reduce costs and improve quality

From improving medication adherence to reducing hospital-acquired infections, pharmacists can play a significant role in critical organizational goals.

Our infographic outlines six pharmacist-led practices that can help improve patient outcomes and reduce overall health care spending. Download it now to get details about each practice, examples of how your peers put them into action, and the resulting impact on quality, safety, and cost reduction.

Download the Infographic