Our Solutions: Component Specialty Billing - Special Business Process Outsourcing Solutions

 

esiPharmD, Exchanging Paperwork for Profit is a unique Medicare Part D pharmacy billing program designed for public and safety net hospitals, hospitals with closed outpatient pharmacy services, nursing homes/rehabilitation facilities, or key independent pharmacy programs.

The Challenge:

Effective January 1, 2006, pharmacies were to begin billing Medicare Part D for many prescription drugs provided to Medicare beneficiaries. ESI has found that after a year of the program being in effect, hospital providers still do not have the necessary administrative protocols in place and are not accurately billing these services.

Is your hospital-owned pharmacy prepared to contract with each Medicare Prescription Drug Plan (PDP), and then submit claims to each of the separate benefit plans offered by the separate PDPs? This is required separately for each of your pharmacy locations.

The new Medicare Part D program is a complete network of carriers administering hundreds of drug benefit plans. If these claims are improperly processed by your staff, it could mean the loss of millions of dollars in reimbursement revenue.

Medicare Part D Complications:

Medicare Part D has brought new responsibilities to the hospital-owned pharmacies. In order to bill for reimbursement from Part D PDPs, pharmacies must complete the following tasks:

• Deductible/co-pay/co-insurance verification
• Collection of patient financial responsibilities
• Utilize new electronic transactions: TrOOP for current enrollment data and B and B-1 transactions for payment
• Comply with unique arrangements for safety-net hospitals related to 340-b pricing
• Each pharmacy location (NCPDP#) must contract directly with each PDP
• Submit claims according to different provisions provided by each of the separate drug formularies offered in each separate plan by different PDP’s, nationally and regionally.

ESI Service Solution:

esiPharmD has been created specifically for public, 340b, and safety net hospitals. As a turn-key billing service, implementation of this solution erases the burden of capturing reimbursement due the hospital-owned pharmacy from Part D PDP’s, as well as providing updated coverage data for PDP formularies, and automated denial tracking, correction, and resubmission of claims.

This program also supports Medicare B and D billing cross-over’s.  esiPharmD is comprised of five key service components which provide a complete outsourcing service solution for Medicare Part D Billing and Reimbursement Management.

• ESI will complete Medicare Part D PDP contracts with each PDP in your region on behalf of each hospital-owned pharmacy location
• ESI conducts beneficiary data preparation and PDP eligibility verification
• ESI handles claims preparation and submission electronically
• ESI manages payor response
• ESI verifies payment has been received by the pharmacy

Why ESI?

• ESI has CMS endorsement for Medicare Part D Claims management
• esiPharmD staff participates on the NCPDP national committee and provides technical assistance to CMS Regional PDP Directors
• esiPharmD is respected by CMS and national PDPs as the field expert
• ESI has experience and great working relationships with UHC-PacifiCare; Member Health, Inc.; Coventry Health Care, Inc.; Medco Health Solutions, Inc.; Aetna, Inc.; CIGNA; Caremark, Inc.; WellCare Health Plans; United Health Plans; Humana; and HISC

Complete Pharmacy Billing:

Overall Pharmacy billing has become more difficult because of NDC, units of measure, brand/generic pricing formularies, and patient financial system limitations. ESI offers a complete pharmacy business practice outsourcing package that includes both PharmD and complete pharmacy billing with data integrity solutions for pharmacy subsystems and your charge master.