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Mastering short-cycle rules can be challenging and confusing. Coding practices can negatively impact your reimbursements if not followed according to Centers for Medicare and Medicaid Services (CMS) short-cycling guidelines. To help avoid the headaches that may accompany common pitfalls, like under-reimbursements due to improper coding, it is important to identify the issues and have the knowledge to remediate them to maximize reimbursements and prevent audits. In this article, you will learn the basics of appropriate coding, how to identify exceptions to short-cycling rules, and how coding ensures transparent communication with the plan.
Whether an independent pharmacy or a part of a chain, pharmacy managers are faced with managing the delicate balancing act between collecting maximum reimbursements from third-party payers and offering competitive pricing to patients who do not have insurance. As part of any business, prescription pricing plays an important critical role in a pharmacy’s revenue and overall success. There are several factors that pharmacies can consider when determining their Usual & Customary (U&C) pricing strategy.  From Average Wholesale Price (AWP), Maximum Allowable Cost (MAC), drug Acquisition Cost (AC), to dispensing software solutions, the time devoted to pricing is critical and not something to be overlooked.
DAW codes are an important part of pharmacy billing and the code used in the prescription will factor into how the third party reimburses the pharmacy. Know what the DAW codes are, how they affect claim adjudication, the impact to your bottom line and technology solutions that can identify potential errors or missed opportunities. These solutions work as safeguards to catch potential errors or missed opportunities both before and after adjudication to help you get paid accurately for what was dispensed.
Split billing can introduce many subtle but complex scenarios and the coding can unexpectedly impact reimbursement and pharmacy workflow. This article discusses the different types of split billing and coverage codes to review before, during, and after adjudication to help reduce underpayment and losses.
When it comes to optimizing prescription claim billing with third party payers and PBMs, effective use of both pre edit and post edit solutions can improve pharmacy revenue. This article discusses the benefits of each solution and how having both can help create a win-win by protecting the revenue you already earned and opening time for your team to grow the business.
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