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Keeping the Promise-to-Pay: Why Pharmacy Claims Reconciliation Is a Must

What does it take to operate a pharmacy? First, you need a pharmacist. Second, you need a physical location to store and dispense medication. Third, you need a supplier to help you stock your shelves. And the list goes on. But what many pharmacists would not think to include on this list — and absolutely should — is a pharmacy claims reconciliation solution.

What is Pharmacy Claims Reconciliation?

Pharmacy claims reconciliation is a necessary process for operating a pharmacy. In this process, you match the amount your pharmacy is supposed to be paid for a medication (known as the point-of-sale adjudication or the promise-to-pay amount) with the amount you received from the payer. In short, you’re making sure you’re getting reimbursed properly, and that you aren’t being shorted due to payer error or oversight.

When you reconcile your pharmacy claims, you’re making sure that the money you think you’re getting is the money you’re actually getting. And that’s important. It’s hard to make decisions for your business when you don’t know how much money you’re going to have in the bank. Also, come tax time, it’s best to pay taxes on the money you’ve actually received rather than the money you think you’ve received.

Do You Think Payers Are Checking Their Own Math?

It’s your money. You owe it to yourself and to the future of your business to get involved. While mistakes in the reimbursement process aren’t common, they do happen. When they happen, you don’t want to be the one who suffers. And you don’t have to be.

When you’re managing your claims, be sure to reconcile them to the claim level to ensure that you were reimbursed correctly for each claim. Knowing that you’re missing a certain amount from a specific payer is a great place to start, but if you can’t pinpoint the specific claim, any correction to that shortage will likely take longer. But you know what generally can’t be delayed? The bills you need to pay with those reimbursements.

When it comes to your revenue, this isn’t the time to play nice. It’s not the time to be polite and wait for the payer to notice their mistake. Make sure you’re getting what you’re owed; no one else is going to be checking up on your claims for you — unless you sign up for a reconciliation service.

What’s the Difference Between Reconciliation Software & a Reconciliation Service?

Many software solution providers out there offer software that can simplify and even automate the claims reconciliation process. But some take it a step further.

When you use reconciliation software, you are taking on the task of using that software and reconciling your pharmacy claims yourself. And while software certainly makes it easier, it still takes time. And, as we’ve heard from many community pharmacists, time is a commodity that most in the industry simply don’t have.

A reconciliation service, on the other hand, allows pharmacists to focus their efforts on patient care and running their businesses. When you use a reconciliation service, an analyst or a team of analysts takes claims reconciliation completely off your hands. They reconcile payments down to the claim level, investigate short payments, and chase down late or missing payments on your behalf. And while a reconciliation service does inevitably cost more than just the software, it’s likely not as much as you think, and the time and headaches it would save you would pay dividends.

When you reconcile your pharmacy claims, you’re making sure that the promise-to-pay is kept. Pharmacy claims reconciliation is a way to give yourself peace of mind that you can pay the bills, compensate your staff, and maybe even take that vacation you’ve always been meaning to take — one day, anyway.

Bottom line: Don’t let your third-party payers be the final authority on how much your pharmacy is reimbursed. Get in there, get involved, and get paid properly.

Make sure you’re getting paid. Talk to a team member today about how Econcile from EnlivenHealth® can give you financial peace of mind.

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