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Medical Billing Versus Pharmacy Billing: What’s the Difference?

Reimbursements are falling. DIR fees are on the rise. To survive, more and more pharmacists are beginning to provide clinical care services for their patients. But for pharmacists new to this side of the business, getting paid for those services can prove to be a challenge.

There are a lot of differences between pharmacy billing and medical billing. If you’re looking to expand your pharmacy offerings, keep the following in mind:

Medical Billing Uses a Different Format Than Pharmacy Billing

One of the first differences pharmacists will notice when trying to bill the medical benefit is the difference in billing formats. Billing third-party payers for prescriptions only uses prescription numbers and National Drug Codes (NDC). Medical billing uses a different set of codes. Pharmacists will need to brush up on the Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) in order to bill the medical benefit of their patients’ insurance plans.

Medical Billing Claims Take Longer to Be Reimbursed

Pharmacists will also notice a difference in their billing timeline. When you bill for prescriptions through a pharmacy benefits manager (PBM), they deny or approve your claims almost instantly. When billing the medical benefit, the wait time is longer. Adjudicating claims can often take up to 14 days after you submit them. If a claim is denied and you need to resubmit it, it can take weeks — if not months — to actually get paid for your services. That’s why it’s so important to get it right the first time.

Pharmacy Claims Are Easier to Submit

Traditionally, pharmacies have had it easy when they submit prescription claims to the PBM. They’re almost always approved as long as a physician prescribed the medication and the drug is on the formulary of the patient’s insurance plan. Billing the medical benefit is different. There are several medical billing policies that can complicate the process, including providing all the proper documentation of the service you provided. This is why it’s important to have the assistance of a medical billing solution to help you submit claims and avoid costly rejections.

The Case for Medical Billing Solutions

The complexities of the medical billing world make billing for clinical care difficult for many pharmacies. Physicians’ offices and hospitals have entire full-time positions dedicated to medical billing and coding — jobs you don’t often find in pharmacies. Billing the medical benefit for clinical care is time-consuming, and time is one thing most pharmacies simply don’t have to spare.

Unfortunately, outsourcing your medical billing to an outside medical billing organization isn’t the answer. With hidden fees, variable costs, and more, you could end up not getting paid what you deserve for your services. Instead, consider using a medical billing solution to streamline and simplify the medical billing process.

A medical billing solution, like FDS MEDBILL, helps you optimize your time, effort, and your reimbursement. For a consistent monthly rate, you can bill the medical benefit with the same amount of effort it takes to submit claims to the PBM. Medical billing solutions help take the guesswork and uncertainty out of billing the medical benefit of your patients’ insurance plans.

Expanding into clinical care is one of the best actions a pharmacy can take. It provides a new revenue stream for your store, plus more health care options for your community. But if you’re not ready to handle the billing side of things, providing clinical care could cause more problems than it solves. Sign up with a medical billing solution, and get paid for all the work you do.


Amplicare is now part of EnlivenHealth®


FDSRX is now part of EnlivenHealth®