Specialty pharmacy billing is a complex and increasingly important part of health care management. As a result of increasing high cost specialty medications as well as the complexity of reimbursement, the challenge of claims management is increasing for any healthcare provider.
What Is Specialty Pharmacy Billing?
Specialty pharmacies mainly focus on specialty drugs for high cost, high complexity medications that may need special handling, administration, or monitoring. Common examples of such conditions include cancer, rheumatoid arthritis, and multiple sclerosis. Among specialty drug pharmacy billing, there are a couple of considerations:
- Drug cost and reimbursement: Specialty drugs are known to have very high costs. Appropriate reimbursement of such costly medications will only be obtained when done correctly by providing accurate billing to avoid denial and low payment.
- Prior authorization for specialty drugs: Many specialty drugs require the insurance company to prior authorize them, that requires a lot of detailed documentation and justification as it is needed to show medical necessity for coverage.
- Complex coding: They require special codes and modifiers with a claim. There is also a significant risk of denial if coded wrongly.
- Patient assistance programs: The patients may need financial assistance or copay support for specialty drugs. This necessitates more billing and administrative management.
- Documentation and compliance: It may be challenging to meet payer requirements or ensure adequate documentation on file. Incomplete or incorrect documentation can lead to claim denial or delay.
Payer Policies: Specialty medication policy may vary between each payer, so knowledge of them and their subtleties in order to bill appropriately is important.
- Delay in reimbursement: Due to the costly and complicated nature of specialty medicines, delay in reimbursement is a very common phenomenon. Follow up and appeals mechanism should not only be timely but also efficient in order to ensure payment on time.
- Accuracy of billing: An accurate billing depends on accurate coding which must include all details pertaining to patient data as well as following payer’s guidelines strictly. Mis- coding will result in claim denial or even under payment sometimes, both of which decrease revenue and may also limit the patient’s medication prescription continuation.
How Sunknowledge Can Help in Specialty Pharmacy Billing
Sunknowledge is the industry leader in healthcare outsourcing, employing the expertise needed to understand the intricacies of billing requirements for specialty pharmacies. That’s how Sunknowledge can effectively change things:
Expert billing services: Sunknowledge offers expert knowledge, specialized in the fine print of the intricacies of specialty pharmacy billing. Their services not only ensure correct coding and timely submissions to payers but also never compromise on the strings attached to payer guidelines. This means fewer denials because of claim rejected reasons and thus higher reimbursement rates to boot.
Prior authorization management: Sunknowledge streamlines prior authorization by handling all the documentation and submission which is required for specialty medications to be approved. This means that a medication can be dispensed without unnecessary delay and compliance is maintained.
Payer policy navigation: With knowledge of various payer policies, Sunknowledge navigates the provider through the complexities of different insurance requirements. Thereby, preventing confusion and ensuring claims are submitted for the first time.
Revenue Cycle Management: One of the very important services Sunknowledge provides revolves around the revenue cycle management service, from claims follow up to appeals and denials management. Their proactive style pushes payments and clears issues that may arise during the process of billing.
Specialized pharmacy billing is an indispensable but often complex area of health care management. Partnering with Sunknowledge enables providers to tap into expert services with the management of complexity, liability, and optimum benefits through efficiency in the revenue cycle. Tailored solutions from Sunknowledge will be able to provide expertise and support for specialty pharmacy providers to conquer common looming issues and, on a broader scale, turn the billing process into better efficiency for both the provider and patient.
Sunknowledge Services Inc. – an ISO 27001:2022 certified, American-owned & operated company, headquartered in New York City – is a leading global provider of Business and Knowledge Process Outsourcing services in the US healthcare domain.
