Pharmacy Reimbursement Division
Purpose Statement
The purpose of the Pharmacy Reimbursement Division (PRD) is to enhance internal stakeholders’ pharmacy billing and financial acumen and help optimize the reimbursement for our medications used within our healthcare system affiliates.
Our Goal
The goal of the division is to assist the health system in maintaining its fiscal responsibility by improving the recovery of medication revenue and identifying cost savings opportunities within the Pharmacy Enterprise.Who We Are
The PRD consists of a team of individuals with expertise in medication billing and reimbursement. The team is led by a Corporate Director of Pharmacy Systems Integration and supported by a Pharmacy Business Manager and Pharmacy Billing Specialist. The team includes a pharmacist, certified pharmacy technician and pharmacy billing specialist.
How We Accomplish Our Goal
Our team accomplishes our objectives by continuously collaborating with our internal and external customers comprised of various interdisciplinary departments (pharmacy departments, billing, patient accounting, revenue cycle IT, revenue integrity, finance, managed care and enterprise clinical information systems) and third party vendors to resourcefully seek innovative pharmacy revenue/cost savings opportunities. We proactively reconcile charges and review Federal, State and Commercial billing regulations while decreasing insurer denials.
Duties/Responsibilities
The PRD operates under the Corporate Pharmacy department. Duties and responsibilities are established to meet the need of our internal and external customers and to support the division’s purpose and mission as well as system-wide strategies.
- Reviews, identifies, and helps affiliates remedy aberrant medication charges
- Performs audits post go-live, either operational or clinical in nature, to ensure that expected outcomes are met and help mitigate unintended consequences
- Responds to pharmacy billing inquiries in a timely manner and offers guidance regarding insurance reimbursement
- Educates affiliates on accurate billing and charge reconciliation to avoid denials and claim resubmissions
- Develops process improvement initiatives to reduce billing inefficiencies or inaccuracies
- Identify, review and oversight for Epic medication billing and reimbursement build and logic
- Implementation and Corporate pharmacy lead for drug replacement, copay and foundation assistance programs