Insights

If you’re a pharmacy leader, the idea of enhancing your revenue cycle can be a difficult proposition. You don’t own the revenue cycle process, but you do own the outcome – and you’re accountable to your  organization’s financial performance surrounding medication use.

There’s no question that pharmacy can play a critical role in optimizing the medication revenue cycle. But if you don’t currently have a seat at the table, how can you gain one? And what steps can you take to get started?

The latest episode of our Pharmacy Innovators podcast, Uncovering the Financial Opportunity of Pharmacy Revenue Cycle, offers answers to those questions. Hosts Jim Jorgensen, Visante Executive Advisor, and Dave Hager, Visante Senior Director, sat down with Lindsey Amerine, Chief Pharmacy Officer at Cleveland Clinic, and Maxie Friemel, Visante Senior Director of Pharmacy Revenue Cycle Services, to get their insights on this topic.

Getting started

In her previous role as System Executive Director of Pharmacy at UNC Health, Amerine started by establishing routine meetings with her revenue cycle and finance colleagues. Her initial focus was on defining common terminology – like what a denial is – and then digging into the data behind it.

“For me, it was all about understanding the data,” said Amerine. “I never went into it saying, ‘we want to own pharmacy revenue integrity.’ I just wanted to understand it. I wanted to know what my financial statement said, what I’m charging and what I’m actually receiving.”

Amerine and her team soon realized that often, there wasn’t a clear reason for why a claim was denied, or why a denial wasn’t appealed.

“There wasn’t anyone clinically looking at these claims,” she said. “So the coders would go in, and if they could recode something to get it approved, they would know that was appropriate. But if it was clinical, they just said we have to accept it. And we said, hang on a second. If we have this wealth of knowledge from clinicians that can do this, why would we write that off?”

Hire the right mix of people

Over time, Amerine’s team expanded beyond just denials and appeals to focus on enhancing the revenue cycle more holistically. She believes the secret to success in this space is building the team with a mix of people who have both pharmacy clinical and operational expertise.

“If you get people that understand both the operations and the clinical side of things, then it’s really been successful for us to pair those individuals together,” she said. “Because if I know the clinical knowledge and everything that went into that decision to prescribe a drug to a patient, and then I know the operational side of what it took to actually dispense that drug and get it to the patient, that’s the final puzzle piece.”

Build on small wins

When working with her clients, Friemel often starts by focusing on the little things that are pain points for the billing team.

“I guarantee it’s going to be some silly NDC that you could fix, and it’s going to prevent a lot of re-work that the teams were doing,” she says. “But if you can solve the little issues, then you’ll slowly gain respect among the other teams. They’ll realize that yes, a pharmacist is capable of being in such a role, and we can learn this. And by the way, we really understand the operations to help solve and prevent some of your issues.” 

Denial management and pre-access challenges are two areas that health systems often struggle with across the board. So Friemel recommends three ways to get started with some quick wins in those areas:

• Reviewing Healthcare Common Procedure Coding System (HCPCS) code changes
• Keeping a clean Charge Description Master (CDM)
• Auditing a sample of claims from your high-dollar drug list

Find the root cause

In her work at UNC, Amerine had an ‘ah-ha’ moment when she realized that the payer reason for a claim denial was typically not the operational reason it was denied.

“We started keeping track of every single appeal that we did,” she said. “And we categorized the payer reason. But we also categorized the root cause. And those two things are very different. So we got a lot of reasons for a ‘no authorizations’ denial, for instance. But when we dug into the root cause, we realized that’s not the real reason.”

“Sometimes the data is super complicated,” added Friemel. “So we like to look at it holistically. Understanding that data set is pivotal. If you can synthesize that and paint a new picture of what the root cause is, that’s very important in this setting.”

Looking for more insights and advice?

Listen to the full podcast episode:

Visante Innovators: Uncovering the Financial Opportunity of Pharmacy Revenue Cycle

Visante helps health systems accelerate their financial and operational performance. With our deep expertise and innovative solutions, we can drive significant value by optimizing your health system pharmacy program. Contact us at solutions@visanteinc.com or call (866) 388-7583 to learn more about how we can support your organization.