Assignment of Benefits
- Understand “assignment of pharmacy benefits.” Typically administered by pharmacy benefit managers (PBMs), under the assignment-of-benefits arrangement a specialty pharmacy will generally ship specific doses of medication for individual patient use. The specialty pharmacy may verify the patient’s insurance information and subsequently bill the patient for copayment.
- Research common types of insurance your patients carry. Learn these payers’ major medical reimbursement policies as well as prescription drug policies and procedures, and incorporate them into your practice model. For example, if you have a high number of Medicare/Medicaid patients in your practice, incorporate current Medicare/Medicaid drug pricing into your revenue model as well as any applicable MACRA or MIPS incentives. For lower-reimbursement payers, allocate staff time more efficiently whenever possible.
- When you submit a drug claim for reimbursement, the place-of-service code is 11. This shows the payer that the therapy was administered in an office rather than another setting (ie, pharmacy, home, mobile unit, etc), ensuring maximum reimbursement.
Have your billing staff submit reimbursement documentation within 24-48 hours to ensure prompt payments and improved cash flow.
More Billing Tips
Avoid superbills. Smaller, more frequent billing cycles are more likely to receive prompt payment than a few large bills each year.
Improve cash flow with adequate staffing. Do not scrimp on billing staff or outsourcing services. Having too little staff to process bills means a possible lack of available funds to cover office and staff expenses.
Always compare actual payments received with payments expected. You will frequently find that payers will under-reimburse versus standard rates, expecting you not to notice. However, if you train your staff to do comparison analyses and/or build the process into your billing software, your practice will be better able to challenge under-payments and more easily receive the correct amounts.
Standard drug and service reimbursement rates can vary greatly. The links below (a sampling of relevant therapies is included in the list below; please note that the list is not all-inclusive) list some of the materials necessary to obtain approval for a prior authorization, reimbursement, as well required J codes for billing.
Note: Drug reimbursement standards will vary by state, payer, region/municipality, and other factors. Drug prices may also change periodically due to inflation or changes in supply/availability.