Specialty pharmacies deal with some of the most complex and rare medications in the healthcare domain. Billing for these items can be equally tricky. Specialty pharmacy billing refers to the management of the reimbursement process of highly complicated, expensive, and difficult-to-manage medicines. This is a multi-step procedure that includes benefit verification, prior authorization, coding, claims filing, and payment settlement.

Charge capture is an essential step in this billing process, the purpose of which is to ensure that all billable charges are captured and reimbursed. Simply put, effective charge capture is more than billing for a prescription; it includes documentation of all chargeable services, coding, adherence to payer requirements, and capturing of all revenues. However, due to the complicated nature of the specialty pharmacy billing process, there are often instances of missing charges, denials, and revenue loss.

This is where specialty pharmacy billing services take center stage. They help in maximizing charge capture and thus improve reimbursement results and make sure that all possible revenue is captured through the pharmacy revenue cycle.

Understanding Charge Capture in Specialty Pharmacy

In specialty pharmacy, charge capture is defined as the process of identifying, recording, coding, and submitting all billable services rendered throughout the specialty medication course.

In specialty pharmacies, charge capture involves much more than just dispensing medications.

•    Specialty medication dispensing
•    Benefit verification
•    Prior authorization management
•    Clinical pharmacist interventions
•    Medication Therapy Management 
•    Care coordination
•    Refill management
•    Clinical assessments
•    Adherence monitoring
•    Pharmacist documentation
•    Infusion services
•    Drug administration support
•    Co-pay assistance coordination

Every lost charge means lost income that may not always be regained. Expert specialty pharmacy billing companies make sure that these are properly documented and turned into proper reimbursement avenues.

How Specialty Pharmacy Billing Services Improve Charge Capture

The process of charge capture is not only about submitting the claims but also about having an efficient billing process which should start before the delivery of the medication and continue till the reimbursement is collected. Expert specialty pharmacy billing services streamline all phases of the revenue cycle to ensure maximum reimbursement and minimize revenue leakage for the specialty pharmacies.

Comprehensive Benefit Investigation

An early point where one can optimize charge capture is through benefit verification. Prior to beginning any therapy, the billing specialists verify the patient's insurance eligibility, medication and health care benefits, formulary limitations, exclusions from the coverage, and the patient's out-of-pocket costs.

Rather than finding problems when filing claims, professional billing firms remove all potential obstacles that might impact the reimbursement process right from the start of the revenue cycle.

The process of conducting benefit checks includes:

•    Insurance eligibility verification
•    Pharmacy and medical benefit check
•    Formulary check
•    Coordination of Benefits (COB)
•    Co-pay assistance programs check
•    Financial assistance checks

All these actions build a solid base for successful reimbursement.

Prior Authorization Management

A number of specialty medications have prior authorization requirements due to their high cost and special indications. Without prior authorization, even accurately coded claims could be refused.

Experienced specialty billing staffs manage the entire process of authorization through gathering of clinical documentation, providing medical necessity documentation, communicating with physicians, following up on the approval, and managing the renewal process. Due to the need for frequent authorizations during the course of specialty treatments, they also ensure continuous monitoring. This helps keep the income of the pharmacy intact.

Simply put, it is another area where specialty pharmacy billing services prove to be very useful for the financial performance of the providers in ensuring that authorization needs are not a barrier to success in payments.

Accurate Clinical Documentation

Proper charge capture relies on thorough and accurate documentation. Any billable service must have documentation that proves medical necessity, eligibility, and performance of the service.

Specialty pharmacy billing companies help providers accurately document patients' diagnoses, lab test results, start of treatment, side effects monitoring, actions taken by pharmacists, medication regimen adherence, patient counseling, refill review, and clinical assessments. Besides helping to secure payment, such documentation greatly assists when passing payer audit inspections.

If there are any documentation omissions, billing experts also work hand-in-hand with pharmacists and physicians to fill in the blanks prior to submitting insurance claims. This strategy is quite effective in minimizing denial rates.

Coding Accuracy

Coding is one of the most complicated aspects in specialty pharmacy reimbursement. In fact, even slight mistakes in coding can lead to payment delays or claim rejections.

Specialty pharmacy billing experts help with proper:

•    ICD-10-CM coding
•    HCPCS level II medication coding
•    CPT procedure coding 
•    National Drug Code (NDC) usage
•    Modifier usage
•    Revenue codes, and 
•    Units of service coding as per payer guidelines.

Instead of depending only on software, specialty coding experts manually review all documents to make sure that the coding not only describes the product but also covers all services involved. This attention to detail improves first-pass claim acceptance while minimizing costly rework.

Claim Scrubbing and Clean Claim Submission

After the submission of claims to the payer, the process of claim scrubbing is undertaken in order to detect any problems that may cause delays or claim denials. Professional specialty pharmacy billing services employ specialized billing software together with payer validation guidelines in order to detect coding mistakes, lack of documentation, incorrect NDCs, erroneous HCPCS or CPT codes, wrong modifier codes, eligibility problems, and prior authorization problems.

This way, expert billing teams are able to increase clean claims rates, lower claim denial rates, speed up the process of reimbursement and save on resources through reduction of rework costs.

Simplify your Specialty Pharmacy Billing with the Right Partner

Specialty pharmacy billing accuracy is crucial for ensuring that claims are not denied, getting maximum payments and having an effective revenue cycle. Cooperation with a qualified specialty pharmacy billing company will help achieve appropriate coding, documentation, payer compliance and charge capture when managing specialty drugs. Work with an experienced billing company that has an impressive history of ensuring 99% accuracy in coding and implementing denial management strategies.

Do not let billing in specialty pharmacy affect your practice’s ability to grow. With the help of specialty pharmacy billing services, you can achieve your financial goals and allow your clinical staff to focus on providing excellent care to their patients.