Do you ever feel confused about your health insurance? The truth is that you are not only the one feeling confused! The majority of mid and small scaled specialty pharmacies feel it difficult to
understand and manage specialty pharmacy billing; and the reason is pretty straightforward. The rules set by insurance companies around specialty pharmacy drugs are very complex to comprehend for
the novice administrative professionals.
This article explains how specialty drug coverage works with your patients’ medical and pharmacy benefits. Plus, it has ways to help you understand their insurance better.
Before you navigate the complex nature of specialty pharmacy billing and insurance coverage, you must know about the background. This will help you in understanding clearly about the recent
updates and how a specialty pharmacy billing
company handles the billing affair efficiently.
Know about the background of specialty pharmacy billing
A long time ago, health insurance only covered “major medical” care, and there was no special pharmacy benefit. In the 1960s, the majority of insurance companies started covering prescription
medicines too. Since that time, the role of Benefit Managers ( PBMs ) started playing a vital role. They help your patients’ insurance companies save money, choose which medicines to cover, and
handle all the prescription claims for you. Over time, they made pharmacy benefits separate from regular medical benefits. Today, three big PBMs manage pharmacy benefits for almost 270 million
people in the U.S.!
Your patient’s health insurance covers medical care and medicines, but they work a little differently. Some people get insurance through work, on their own, from Medicaid, or TRICARE. These plans
manage medical and pharmacy benefits separately. That’s why your patients might have one card for doctor visits and another card for medicines.
If your patient is on Medicare, it’s split into parts
- Part A: covers hospital stays.
- Part B: covers doctor visits, home care, and some medicines given by a doctor.
- Part C: covers most prescription medicines.
It’s like having different pieces to cover all your patient’s health needs!
Now, you need to have clear ideas about pharmacy benefits and medical benefits for your patients with Medicare
Pharmacy benefits
When your patient needs a special medicine, a doctor might teach your patients on how to take it at home. This could be a pill, cream, shot, or something through an IV. Usually the medicine is
covered by your patient’s pharmacy benefits when they take the medicines administered by you at their home.
Your patient’s insurance company is the one that determines a lot about how your patients should get their medicines. They might make rules like
- Only using certain pharmacies.
- Trying other medicines first ( step therapy ).
- Limiting what’s covered ( formulary restrictions ).
- Adding extra costs ( copay accumulators ).
Medicines are put into groups called tiers. Cheaper or generic ones are in Tier 1. Special medicines are in Tier 4, which costs your patients more. Your patients may have to pay more out - of -
pocket payments especially when the tier is higher.
Medical benefits
Remember that a patient can be prescribed specialty medicines by a doctor or nurse working in a clinic, hospital or infusion center and this is what is known as medical benefits. Here’s how it
works:
- The doctor buys the medicine and keeps it ready.
- After giving it to your patient, you need to send the bill to their insurance company.
- The insurance pays the doctor of your patient later.
Your patients may be have to pay some amount of money as deductible, copay, or coinsurance when their prescribed medicines are covered this way.
If a patient has Medicare
- Medicare Part B pays 80 % of the cost.
- Your patient’s insurance company pays the other 20 %, or the extra amount
Since this doesn’t involve the pharmacy benefit, you don’t have to worry about extra rules like step therapy or special pharmacy requirements.
Health insurance can be really confusing. In the United States, healthcare is tricky and has lots of rules. That’s why it’s smart to ask an expert specialty pharmacy company for help. A specialty pharmacy billing company has a
team of experts who know all about insurance and how your specialty pharmacy’s revenue cycle management works.
These experts in a specialty pharmacy billing company can
- Get the right approval for your special medicines.
- Make sure your patients’ insurance companies are billed correctly.
- Help you find programs to save money and make it easier to get the maximized reimbursements for the provided specialty drugs.
A specialty pharmacy billing company always enables your specialty pharmacy to save almost 80 % of operational costs while giving a solid boost to your overall practice.