Learn About the Importance of Pharmacy Claims Reconciliation

The business side of running a pharmacy is sometimes as important as the healthcare side. You’re operating a small business, so you must ensure that you’re getting properly compensated for your work.

That’s what pharmacy claim reconciliation is all about. It’s making sure you’re properly reaping the benefits of your hard work.

Just like the rest of the pharmacy industry, pharmacy claims reconciliation can look overly complicated and intimidating — which isn’t incorrect.

Nevertheless, it’s essential to know what it is and how your pharmacy be properly reimbursed for the work you do.

What is Pharmacy Claims Reconciliation?

Pharmacy claims reconciliation is defined as a process where you “match the amount your pharmacy is supposed to be paid for a medication... with the amount you received from the payer.”

In essence, pharmacy claims reconciliation is about getting properly compensated for filling a prescription.

Whether it’s getting paid too much or not enough, pharmacy claims reconciliation ensures that the end of the year isn’t too much of a headache.

Tax season is a stressful time for anyone and any business. Getting your numbers in order will ensure that your independent pharmacy is free of any problems with the IRS or any tax-related problems.

Get Your Bottom Line in Order

Many factors contribute to reimbursement errors. Though processing insurance claims with technology are easier than it was without, things are always bound to fall through. Human error is possible, even with the reliability of technology.

Pharmacy claims reconciliation is a crucial aspect of running your business. Though things might seem great at the moment, you could be in for a rude awakening if you don’t pay attention to the fine details.

Running a business requires exceptional attention to detail. In order to be at the forefront of the industry, you have to play the role of part pharmacist, part business person — and we’re here to help.

How to Receive Proper Compensation

Each prescription takes a lot of time to process, fill, and sell. Even the simplest or most common medications require pharmacists to cut through a slew of red tape.

Each part of the process has its own steps and parts. Some are relatively simple and others need some more attention. Regardless of the supposed difficulty, every prescription has its own pitfalls and wide margins of error.

Here are a few ways you can get properly compensated:

Use Electronic Remittance Advices

Billing errors are inevitable, whether due to a medication order or an insurance mishap. At the end of the day, your pharmacy’s bottom line falls on your shoulders — but it does not mean you have to go at it alone.

Enter electronic remittance advices (ERAs). They “outline how much a plan paid a pharmacy on a claim and any adjustments that were made.”

ERAs supply information about a transaction, ensuring that every claim — whether that be with a doctor’s office or insurance plan — is processed properly.

They look at factors that could affect a claim or payment such as:

  • Contract agreements
  • Secondary health plans
  • Plan benefit coverage
  • IRS withholding

In short, ERAs help make the reconciliation process less of a headache. They help you maintain your pharmacy’s workflow by letting you focus on more urgent pharmacy tasks.

They allow you to focus on the task at hand while not neglecting the value of your pharmacy claims. Net-Rx is one such ERA that works with all major pharmacy vendors.

Though ERAs are extremely helpful for your pharmacy, you shouldn’t give them full autonomy of reconciliation. Be as informed and involved as possible during the reconciliation process.

Though ERAs are there to help you out, it is your independent pharmacy at the end of the day.

Separate Pharmacy Reconciliation from Medical Reconciliation

As the term suggests, pharmacy claim reconciliation lies squarely on the commerce side of pharmacy work. It has less to do with medication doses and more with reimbursement rates.

Medical reconciliation fulfills the other side of that equation, focusing on the health side of healthcare.

The National Library of Medicine defines medical reconciliation as the “formal process for creating the most complete and accurate list possible of a patient’s current medications and comparing the list to those in the patient record or medication orders.”

Medical reconciliation is done to avoid medication errors such as dosing errors, drug interactions, and unnecessary duplications. Just like its pharmacy counterpart, medical reconciliation helps streamline a patient’s profile and does away with the familiar pitfalls of pharmacy work.

Though medical reconciliation is mainly relevant to hospital and medical work, independent pharmacies play an invaluable role in the process.

Your pharmacy software system should give you a comprehensive look at your patient’s profile. It should clearly show the current state of their health journey through the medications they take, how much of it, and how often.

How Pharmacy Claims Reconciliation Can Help You

All in all, pharmacy claims reconciliation ensures that you and your pharmacy are getting their proper dues.

Most pharmacy software systems already have some reconciliation capabilities, but feel free to explore more options if you don’t feel they’re doing enough.

It’s your independent pharmacy. You call the shots. You’re the one people look to for the hard decisions.

Make sure your pharmacy is getting proper compensation so you can continue delivering exceptional care for your community.