Strategies To Optimize Your Pharmacy Revenue Cycle - ASHP Media

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Strategies to Optimize Your Pharmacy RevenueCycle9/2/2020Strategies to Optimize YourPharmacy Revenue CyclePaul W. Bush, PharmD, MBA, BCPS, FASHPVice President, Global Resource Development andConsultingDavid J. Warner, PharmDSenior Consultant, ASHP ConsultingDirector, Center on Practice ng.ashp.org1

Strategies to Optimize Your Pharmacy RevenueCycle9/2/2020PresentersAdrianne (Maxie) Friemel, PharmD, MS, BCPSManager, Revenue Integrity Pharmacy &OncologySCL HealthGrayson Peek, PharmD, MS, BCPSManager, VMG Clinic PharmacyDepartment of Pharmaceutical ServicesVanderbilt University Medical CenterGene Rhea, PharmD, MHAAssociate Chief Pharmacy OfficerRetail and Specialty Pharmacy ServicesDuke University Hospitalwww.ashp.org/certificatesSAVE 50 withcode presented atthe conclusion ofthe webinar 100% online, complete on own time 16.5 hrs of CE presented in 9 modules Pass comprehensive exam to earn ASHPProfessional Certificate2

Strategies to Optimize Your Pharmacy RevenueCycle9/2/2020Impact of the Pandemic on Hospital FinancesChallenges for om‐COVID‐19 ne‐2020.pdf3

Strategies to Optimize Your Pharmacy RevenueCycle9/2/2020Imperatives for om‐COVID‐19 dBillingForMedicationsWhitePaper09172014.pdf4

Strategies to Optimize Your Pharmacy RevenueCycle9/2/2020Presentation Outline1. Optimal Revenue Cycle Management Program1.2.3.4.Creating a case for a revenue cycle programRevenue cycle program structureInvolving pharmacist leadershipPut a revenue cycle program to practice2. Revenue Improvement and Preservation Strategies1.2.3.4.Timely and accurate coding and documentationCharge Integrity monitoring and metricsData management and reportsSite of care and plan shifting considerations3. Clinical Review Board for High Impact Drugs1.2.3.4.Impetus for launching the review boardRoles ‐ Medical Administration, Pharmacy, PRMO, FinanceWorkflowProgram ImpactOptimal Revenue Cycle Management ProgramAdrianne (Maxie) Friemel, PharmD, MS, BCPSManager, Revenue Integrity Pharmacy & OncologySCL Health5

Strategies to Optimize Your Pharmacy RevenueCycle9/2/2020Building a TeamWho’s Who in Revenue CycleClinical nBilling/CodingClaim ReviewClaimSubmissionDenial & AppealsPayment ctModeling3rd Party PayerPatientAccounting/CDMCharge CapturePharmacy Build6

Strategies to Optimize Your Pharmacy RevenueCycle9/2/2020Pharmacist csPharmacyBillingCompliancePre‐AccessPut it to PracticePatient Order: Cycle 1, Doxil 80 EditClaimErrorReviewDenialReviewPharmacy Revenue Cycle Program7

Strategies to Optimize Your Pharmacy RevenueCycle9/2/2020Key TakeawaysBuild an interdisciplinary team withpharmacist at the tableUnderstand how revenue cycle isperformed and integrate yourself withinthe entire cycleContinue to maintain and discover moreopportunityRevenue Improvement and Preservation StrategiesGrayson Peek, PharmD, MS, BCPSManager, VMG Clinic PharmacyDepartment of Pharmaceutical ServicesVanderbilt University Medical Center8

Strategies to Optimize Your Pharmacy RevenueCycle9/2/2020Timely and Accurate Coding and DocumentationToo SoonToo LateBilling/codingcomplianceLater receipt ofpaymentLack ofcomprehensivecharge captureHigher cost to collectpaymentNeed forregeneration ofclaimsRisk for duplicatechargingOrganizationsshould findappropriate balanceof timelydocumentation andreceipt of payment.Goal (e.g. 4 days)Charge Integrity Monitoringand MetricsPharmacy ownership andresponsibilityProspective andretrospective methodsMetrics Capture of missing charges ( )Denials (# and/or )Accuracy of modifier application (%)Time to process work queue items (# of days)Time to release of claim (# of days)Drug expense/WAC% exposureMonthly/annual financials9

Strategies to Optimize Your Pharmacy RevenueCycle9/2/2020Charge Integrity Monitoring and Metrics Example: Configuration of work queues within theEHR for charge outliersPharmacyOutlier ( )Outlier (billing units)Central pharmacy 1,000975OR Pharmacy 1,000800Oncology / SpecialtyInfusion Pharmacy 5,000500Clinic AutomatedDispensing Cabinets 50080010

Strategies to Optimize Your Pharmacy RevenueCycle9/2/2020Unreconciled dispense reportsData Management and Reports Charge greater than X without a subsequent administrationClinical team contacted to resolve lost charges Risk for duplicate chargingDaily review with shared responsibilityComprehensive chargemaster report Transition from traditional chargemaster to individualdrug file records within the EHRSite of Care and Plan Shifting ConsiderationsSite of CareHospitalbasedlocationPlan ShiftingFree‐standinglocation or home‐infusionKey Points Payer cost containment strategy Requires high‐functioning PA process Inability to purchase drug at 340Bpricing Ability to maintain continuity of care?MedicalbenefitPrescriptionbenefitKey Points Payer cost containment strategy Unable to buy‐and‐bill throughmedical benefit Requires high‐functioning PA process Brown bag, white bag or clear bag Significant operational adjustments11

Strategies to Optimize Your Pharmacy RevenueCycle9/2/2020Key TakeawaysRevenue IntegrityProspective and retrospective methods should be utilized toensure integrity of pharmacy chargesRevenue Improvement and PreservationSignificant operational adjustments exist with evolving payercost containment strategiesData Management and ReportsA multi-modal approach is recommended for revenue cyclemonitoring through the utilization of data and reportsClinical Review Board for High Impact DrugsGene Rhea, PharmD, MHAAssociate Chief Pharmacy OfficerRetail and Specialty Pharmacy ServicesDuke University Hospital12

Strategies to Optimize Your Pharmacy RevenueCycle9/2/2020High Impact Review Board Impetus for Launching Review BoardIncreasing approval ofvery high costpharmaceutical agents Spinraza CAR‐T Agents Lutathera ZolgensmaPayer mandates forpredetermination orpreauthorization prior toinitiation of therapy Requirements arepayer dependent Some payers mayrequire single caseagreements withspecific criteria forpayment Process is timeconsuming and led todelays in treatmentwith suboptimalcoordinationFinancial risk forinstitution Risk dependent oncourse of therapy –higher risk for longercourses of therapy Payment informationgenerally notavailable to front lineproviders sotransparency requirespartnershipHigh Impact Review Board Membership and RolesMedical LeadershipPharmacy Chief Medical Officer Physician Champions Chief Pharmacy Officer Pharmacy Administrators and CliniciansRevenue CycleManagementSpecialists Revenue Cycle Leadership Predetermination/authorization Specialists Payer ContractingEntity Finance Charge Master Liaison Hospital Administration13

Strategies to Optimize Your Pharmacy RevenueCycle9/2/2020High Impact Review Board Workflow of Review ProcessWeekly MeetingsCase Information Forwarded to BoardMembersProviders Submit Patient CaseIn Meeting Case ReviewsMedical Appropriateness ReviewFinancial Determination ReviewCase DeterminationApproval to ProceedFurther Investigation NeededHigh Impact Review Board Review of Board Financial ImpactDrugFY20 DosesBilledTotalPaymentOpen inPayments Percentage ProcessingPartialPaymentDenial Received(active follow‐up)Denial rineura1010100%0200Azedra2150%1000Grand Total51249997%9103114

Strategies to Optimize Your Pharmacy RevenueCycle9/2/2020Key TakeawaysNew Drug Agents Can Be Very ExpensiveHigh acquisition cost of certain new infused medicationsmake the risk of claims denials exponentially more financiallysignificantMultidisciplinary Coordination is KeySuccess can be had with a multidisciplinary team includingphysician champions, revenue and payer relations specialistswhile following a defined review and approval processTracking Performance is ImportantTracking the reimbursement status of key high impact agentscan provide feedback to providers and hospital leadershipthat the institution is recouping its costs for providing highquality carePanel Discussion and Q & A15

Strategies to Optimize Your Pharmacy RevenueCycle9/2/2020www.ashp.org/certificatesSAVE 50 withcode PRCM50 atcheckout 100% online, complete on own time 16.5 hrs of CE presented in 9 modules Pass comprehensive exam to earn ASHPProfessional Certificate16

Strategies to Optimize Your Pharmacy Revenue Cycle 9/2/2020 5 Presentation Outline 1. Optimal Revenue Cycle Management Program 1. Creating a case for a revenue cycle program 2. Revenue cycle program structure 3. Involving pharmacist leadership 4. Put a revenue cycle program to practice 2. Revenue Improvement and Preservation Strategies 1.

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