Implement the Best Denial Management Strategies in Specialty Pharmacy Billing
No one likes a denial—whether it is a romantic “thanks, but no thanks” or the dreaded “your credit card has been declined” at checkout. But when running a specialty pharmacy practice, claim denials are like receiving a bouquet of broken promises. Imagine the frustration of seeing those hard-earned dollars slip away because of a denied claim, all while trying to balance your books and keep the shelves stocked. Just like a rejected love proposal, a claim denial can sting, but unlike matters of the heart, you can tackle this one with a little help and a lot of expertise.
Denial management is a crucial step in your specialty pharmacy billing services as it ensures you are optimally reimbursed for pharmacy claims and healthy revenue. Poor denial management plan often leads to denied claims, payment delays and substantial revenue leakage for your practice.
According to a recent survey conducted by the Financial Management Association (HFMA), almost 60% of medical claims are retrievable, thus indicating that you can still manage to prevent a sizable portion of claims.
Fortunately, you can implement a robust denial management process in your specialty pharmacy billing by following the strategies mentioned below-
Proven strategies to implement a perfect denial management process:
1) Improve the clinical documentation process:
Inadequate or inaccurate documentation is one of the common reasons behind claim denials. You can improve the documentation process by establishing strict policies and procedures that ensure clean and accurate documentation. Additionally, you should provide your administrative staff with training sessions on advanced documentation methods. Additionally, you should leverage an advanced technology platform like Electronic Health Records to improve your overall documentation approach.
2) Inaccurate coding:
Most claim denials in a specialty pharmacy billing process are caused by error-full coding. As your specialty pharmacy practice involves lots of specialty medications, your in-house coding team requires navigating the intricate nature of specialty pharmacy codes. Unfortunately, a single mistake in the coding process can lead to claim denials, payment delays and revenue leakage at the end of the fiscal year. Your team needs to have sound knowledge and expertise on the most up-to-date specialty pharmacy codes to avoid errors. Keep your specialty pharmacy coding staff trained and educated with the latest coding guidelines and cheat sheets.
3) Lack of prior approval:
Several specialty pharmacy drugs require you to take prior approval from a patient’s insurance company before administering them. Failure to get prior approval can cause your practice to face denials and unexpected out-of-pocket expenses for your patients. You need to employ a dedicated staff for managing prior authorization. Each insurance company has its own set of prior authorization regulations, and they frequently update the list of specialty pharmacy drugs requiring PA approval. The PA staff should stay on top of all the PA rules and regulations and should be familiar with diverse types of PA form structures.
4) Maintain a robust compliance process:
Your specialty pharmacy billing process must comply with all the regulations and guidelines related to billing and reimbursement guidelines. A stringent compliance monitoring method enables your practice to avoid denials caused by non-compliance. Your staff should review policies regularly to remain up to date. You should invest in staff training to ensure proper adherence to compliance to enjoy specialty pharmacy medical benefits.
5) Continuous improvement:
Denial management is not a fixed process as it requires you to take effective measures to ensure continuous improvement. You should run regular reports and analytics to understand denial data, real-time trends and patterns and leverage proper steps to avoid future denials. A continuous improvement approach helps you make your process optimized and seamless.
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6) Develop a denial management team:
To ensure a seamless denial management system, invest in building a top-notch team of denial management experts. This team should encompass specialists in patient onboarding, insurance verification, specialty pharmacy coding, AR management, and billing to oversee end-to-end specialty pharmacy billing and denial management.
Denial management in specialty pharmacy billing isn't straightforward. To sidestep these complexities and streamline your claim reimbursement process, many practices opt to outsource their billing and denial management to third-party revenue cycle management companies. By outsourcing, you can concentrate fully on delivering exceptional clinical care, while your billing and specialty pharmacy billing and coding company expertly handles claim denials, ensuring optimal reimbursement flow for your practice.
Dorian Wilfred from New York, United States, boasts over a decade of expertise as a medical transcriptionist, specializing in healthcare medical billing, revenue cycle management, and claim administration. With a keen eye for detail, he excels in collecting funds from insurance companies in the USA, ensuring accuracy and compliance. Dorian's proficiency has significantly contributed to streamlined communication among healthcare providers and optimized financial operations.