5 Important Steps To Optimize Reimbursement For Your High-Cost Pharmaceuticals and Laboratory Testing

What are the important steps to optimize reimbursement for your high-cost pharmaceuticals and laboratory testing?

Here are five keys:

1. Document and code. Verify that prescribing physicians have adequately documented the order in the patient chart and that the medical records department recognizes the order and uses the ICD-10 procedure code.

2. Review managed care contracts. Review your managed care contracts in depth of top payers for specific clauses pertaining to high-cost pharmaceuticals and high-cost lab testing. If these clauses exist, identify the payer’s coding requirements.

3. Audit your Chargemaster quarterly. Capture and code and all charges associated with high-cost pharmaceuticals and lab tests. Ensure that all the appropriate codes are identified and entered into the Chargemaster with the correct pricing.

4. Develop a managed care contract strategy. Negotiate special provisions in your managed care contracts for high-cost pharmaceuticals, orphan drugs and lab testing. Four types of contract-provisional clauses that apply to most high-cost drugs and lab tests include: trailer claims, carve-outs, cost outliers, and stop-loss thresholds.

5. Map your managed care reimbursements to actual payments. To ensure manage care contracted reimbursement, compare actual payments to specified agreement terms.

Call VIE Healthcare to schedule a call to learn how your hospital can implement best practices in high-cost drug revenue optimization at 1-888-484-3332 ext 501 or email me at lmiller@viehealthcare.com.