Off-label use of claim editing

I remember the first time I worked in a pharmacy like it was yesterday. Not only was it fast-paced and exhilarating, the work also was meaningful and beneficial to the community. I can hardly believe it’s been close to 20 years since I began behind the counter. Today, my work is still in the industry, helping to build products and services for all types of pharmacies – chains, independents, grocers and everything in between. In this rapidly changing healthcare environment, pharmacies must utilize all of the tools at their disposal to not just remain financially viable but thrive as a provider of healthcare.

One of those tools is switch-based claim editing. And yes, my last sentence may well have caused a collective eye roll. But please keep reading. Claim editing has been around for decades but it’s not just for AWP and DAW updates any longer. Today’s editing platforms are flexible and scalable and when fully leveraged can help drive pharmacy success. The following are just a few examples of the “off label” uses for claim editing that can help your business.

Recalls and Discontinued Products
By continuously monitoring FDA communications, a claim editing tool can activate real-time edits to notify pharmacy employees of recalls and discontinued products at point of fill. While both wholesalers and software vendors also provide these updates, the ability of claim edits to trigger notifications within hours of the alert right at point of dispensing is important, especially for recalled products.

Custom Messaging
Claim editing is no longer one size fits all. Savvy owners and chains are using customized messages to drive unique business goals.

•    Inventory Management
Whether it’s because of excess inventory or better acquisition costs, pharmacies often have preferred products. Claim messages triggered when a non-preferred NDC is utilized can encourage staff to consider your preferred alternative. The significant impact inventory management has on the bottom line makes it a great area to consider customized editing.

•    Loyalty and Customer Engagement
Pharmacies are competing for market share for prescriptions, front of store sales and healthcare services. Because of this many of them have carved out niche programs for a variety of health conditions for humans and even pets. Triggering immunization reminders based on payer or alerting a diabetic patient receiving insulin of additional support services are just a few examples. The possibilities for how customized claim editing can help drive these programs are endless.

•    Automated Field Population
We all have those special circumstances that require rare claim fields to be populated. Claim editing is a great way to automate a process that might otherwise require numerous key strokes or toggling to infrequently used fields and screens. For instance, you can automate the entry of incentive fees on immunization claims or auto populating unique field requirements for state specific Medicaid claims. Again, when you find yourself or your staff losing efficiency, revenue or time due to unique claim requirements, consider that claim edits could help.
These are just a few examples of the numerous possibilities for claim editing as a solution to pressing industry challenges. Hopefully, by scratching the surface of available and evolving claim editing options, you can consider other ways to better leverage claim editing for your business.

About the Author
Jonathon Kopf is a pharmacy product manager for Emdeon, a leading provider of healthcare revenue and payment cycle management and clinical information exchange solutions in the U.S. healthcare system. He has worked in the pharmacy industry for more than 15 years, starting in the trenches as a pharmacy technician. Prior to joining Emdeon, Jonathon has held various roles in both retail pharmacy and pharmacy benefit management. He holds a bachelor’s degree in management with a health organization focus from Texas Tech University.



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