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.Many times managed care payments miss the high-cost drug payments and this is a lost revenue opportunity for hospitals. Click To Tweet