Pharmacy Revenue Cycle Solutions
The Pharmacy Revenue Cycle should be a primary focus for all hospitals. Complete understanding of its' complexities, from acquisition to payment, ensures compliance and minimizes lost revenue. SunStone can help you get a handle on the entire process, identify systemic issues and develop plans for improvement.
Pharmacy System & Pricing Most hospitals actively maintain their CDM to ensure accuracy. However, drug management often falls to Pharmacies due to complexities around NDCs, AWPs, HCPCs coding, unit issues and unknown charging mechanisms inherent in Pharmacy Information Systems. Implementing a process that leverages Pharmacy, Information Services and Finance can significantly reduce pricing errors.
Providers employing “best-practices” maintain a process that assigns responsibility for:
Formulary and Non-Formulary items AWP, AWP factors and AWP update schedules Non-Formulary Standards and Protocols Price Schedule maintenance and updates Formal drug mapping into price schedules Understanding price formulas and costing strategies PharmD Clinical Intervention Services
Managing the CDM SunStone has many tools to help assess your CDM’s accuracy and identify opportunities:
Claims editor software targets coding and drug unit errors to identify potential rebilling opportunities Claims sampling verifies documentation, charging, coding, units and billing of Pharmacy services Market assessments identify variances that account for errors in HCPCS code assignment or units
Be sure to also dedicate time to compliance issues. Take care to adhere to Self-Administered drug regulations, Compounded Drugs, Pre-Administration related services for IVIG and newly approved FDA drugs and applicable HCPCS coding. Being compliant mitigates risk and ensures that you recoup costs related to services rendered.
National Drug Code (NDC) Reporting Mandate Hospitals must develop and maintain two distinct crosswalks to convert dosage into billable HCPCS units and NDC units which are two distinctly different conversions. SunStone can help you get a handle on the entire process, identify systemic issues and develop plans for improvement.
Ensure the formulary at your hospital has the accurate NDC codes for active line items Validate the HCPCS code assignment for active line items Review pharmacy information systems “to ensure there is a mechanism to track and transmit the NDC code” Verify that NDC unit qualifier, NDC units and HCPCS units conversion tables “are accurate and validate the interface from the pharmacy to the billing system,” Audit processes to verify that the NDC unit qualifier, NDC code, HCPCS code, NDC units and HCPCS units for the drug administered are correctly populated on the claim form Review Medicaid transmittals to identify line items and or claims that have been rejected and track the denials in their totality to proactively resolve issues
For detailed information about SunStone Consulting Pharmacy Revenue Cycle Solutions, please contact Vonda Moon at 717-600-0314 or via email at vondamoon@sunstoneconsulting.com .
