Optimizing pharmaceutical reimbursement: One institution's approach.

摘要

PURPOSE: The importance of understanding the revenue cycle, reviewing the billing system for errors, and collaborating with other health system departments in maximizing pharmaceutical reimbursement, and the approach used at a large academic medical center to justify a reimbursement specialist and achieve this goal are discussed. SUMMARY: Understanding the revenue cycle may enable pharmacy departments to make wise decisions about programs and services that maximize revenue recovery and meet patient needs. Parts of the revenue cycle that pharmacists can have a favorable effect on include claim denials/payment variances, regulatory changes, compliance, contracting, and price setting. Pharmaceutical reimbursement was increased substantially at one institution through a collaborative effort involving multiple departments and a reimbursement specialist who analyzed the revenue cycle, reviewed billing systems, and took steps to avoid or correct billing errors. CONCLUSION: Collaborating with members of key health system departments can help identify and resolve billing system errors that diminish revenue. Documenting efforts to increase revenue recovery can help justify adding personnel dedicated to reimbursement matters. Analyzing the revenue cycle can contribute to wise decision-making that optimizes pharmaceutical reimbursement.