NCPDP specifications provide for real-time eligibility, billing, adjudication, and payment transactions. Because those transactions are so efficient and predictable, they are assumed to be 100% correct and final.
In fact, in the case of hospital outpatient pharmacies they are not.
Other hospital information silos benefit from oversight by existing revenue cycle processes but the outpatient pharmacies typically have not been linked to those processes.
Patient Accounting
It is presumed that every prescription is covered by an insurance or government benefit program, a charity program, or is self pay and that prescriptions are not filled unless they are paid for. Pharmacists and pharmacy systems are obviously focused on flawless and efficient delivery of pharmacy services, not billing of claims. Hospital pharmacy systems are not selected with patient accounting as a primary criterion.
Prescription Coverage
The reality is that many hospital outpatient prescriptions, particularly those filled at safety-net hospitals, are not paid for at time of service. That is because pharmacy systems are designed to take data very literally and therefore not do any self-correction. However, when searching for third-party coverage, a healthcare billing system may need to make assumptions about certain query parameters. It may need to access multiple data sources and alternate queries or it may need to make decisions about demographic data based on state, local, or hospital business rules.
Hospital patient accounting systems generally accept electronic remittance advices (RA) to format posts to their accounts. Healthcare X12N 835 (RA) transactions are passive asynchronous communications. In a pharmacy environment immediate synchronous NCPDP responses are required and very often the RA is sent as a paper document or print file. Reconciliation of pharmacy claims can be cumbersome at best and impossible at worst.
How Medidal can take Outpatient Pharmacies from Budget Line Item Expense to Revenue Center
Medidal's Provider Advantage Service™ finds third-party payer coverage for any healthcare delivery system, including pharmacy, so missing eligibility for prescriptions can be found, corrected, and billed by Medidal or the pharmacy system. In addition, Medidal's FileScooter™ is perfect for creating electronic transactions from paper documents or electronic office files. Any X12 or NCPDP transaction or other formatted file or document that is required by a pharmacy system for reconciliation can be created with FileScooter technology.
By linking missing account information to the front-end and the back-end of the pharmacy system, existing hospital revenue cycle processes can contribute to outpatient pharmacy oversight.
