You’ve seen the sign, probably early fall, posted right there on the marquee of the local pharmacy: “Most insurance accepted.” It means that when a patient stops by the pharmacy for a flu shot, the pharmacy can probably bill the health plan for the covered medical benefit. Quick, easy and (mostly) painless. This trend in retail medical claiming, or covering and billing for medical benefits at the pharmacy, is quickly spreading to other products and services, and is largely expanding the scope of convenient, clinical care options for both the patient and the pharmacy.
The numbers are staggering. Influenza alone is a serious virus that results in more than 200,000 hospitalizations annually. Yet, the Centers for Disease Control and Prevention report that only 28% of healthy, non-high risk adults ages 18 to 49 years received the vaccination in 2010. Among the myriad of reasons why patients purport they do not receive the vaccination are fear of needles, safety concerns or not wanting to contract the virus. The pharmacy industry is in a unique position to not only serve as a handy destination for receiving vaccinations, but to also maximize the opportunity to provide patient education on the health benefits of vaccinations. Clearly, that role has been amplified in recent years and will likely continue to grow. According to the American Pharmacists Association, the number of pharmacists nationwide trained to deliver vaccines has quadrupled since 2007.
Until now, one challenge to expanding retail medical claiming has been the amount of items included on the health plan formulary (i.e., list of approved drugs or items). Health plans typically temper their formularies with the most commonly prescribed drugs, dosage amounts and durable medical equipment needed to manage certain conditions. Since formularies can change often, they are considered to be living, breathing documents. The good news for the pharmacy is that as the health plans modify their formularies, the changes can typically be processed and enacted via the pharmacy technology software very quickly across the entire software system. As an example, if the CDC reports a shingles outbreak in the United States, and the commercial health plans alter their formulary to include the vaccination Zostavax, usually those edits can be rolled out within an hour, and pharmacies can immediately begin billing the health plan for administering Zostavax to their customers. The ability to be nimble in the face of the ever-changing healthcare landscape is vital to the pharmacy in the environment of retail clinical care.
Nevertheless, retail medical claiming extends beyond billing for vaccine administration and is designed to operate entirely within the standard pharmacy workflow, which reduces the traditional labor intensive paper-billing processes or manual entry of web-based services. By determining eligibility and patient co-pay and deductible information in real-time at the point-of-sale, pharmacies can improve payment rates for medically eligible services. And at the end of the day, having a revenue source for a pharmacy performed service identified before the patient leaves the pharmacy exponentially increases the likelihood of that encounter resulting in a paid claim.
All-in-all, we can probably expect to see an increase across the board. Increase in pharmacies performing vaccinations and other non-urgent clinical services, health plans expanding their formularies, more paid claims for medical benefits and, hopefully, a greater percentage of patients receiving a flu shot!
Mike Carmody is the director of DME/MedRx pharmacy services at Emdeon. He is responsible for pharmacy solution product development and workflow efficiencies. Emdeon is a leading provider of revenue and payment cycle management and clinical information exchange solutions, connecting payers, providers and patients in the U.S. healthcare system.