Optimize Reimbursement for Pharmaceutical and Laboratory Test Costs

5 Important Steps To Optimize Reimbursement For Your High Cost Pharmaceuticals 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 quarterlyCapture 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.
Many times managed care payments miss the high-cost drug payments and this is a lost revenue opportunity for hospitals. Click To Tweet
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.

Lisa Miller

Lisa Miller

Lisa Miller is a consultant, speaker, and podcast host. Her consulting firm, VIE Healthcare, has provided services to over 1,000 hospitals and organizations since 1999.

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Discover 15 Effective Cost Savings Strategies That Most Hospitals Can Apply Right Now

Learn how these five principles can help you reduce costs immediately.

VIE Healthcare 15 Effective Cost Savings Strategies Report Cover Image

A strategy developed from analyzing over 5,000 hospitals

A simple step-by-step plan in plain language

Proven processes to organize and motivate your team to find savings

We protect your information