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 health care 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 Senior Pharmacy Reimbursement Specialist. All team members have a background as a pharmacist, certified pharmacy technician.

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 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 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
• Implementation and Corporate oversight for drug replacement, copay and foundation assistance programs

Pharmacy Reimbursement Division Leadership