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Pharmacy Analysis

A Single Solution For Managing Your Pharmacy And Chargemaster


For pharmacy operations, reliable data — data that's both visible and available — is where it all begins. In a single platform, VitalCDM provides the insight into your pharmacy data that enables you to identify root causes for missing, outdated, or erroneous information and/or coding that may be slowing (or slowly strangling) your billing and reimbursement cycle.

Key Benefits For Your CDM Manager and Revenue Integrity Team

Vitalware Pharmacy Analysis offers tools and information specifically created to help manage the complexities of the pharmacy file in your chargemaster.

Be confident your pharmacy file is fully compliant.
  • Identifies inactive or deleted HCPCS codes and suggests replacements
  • HCPCS to revenue code comparison identifies pairings that need review
  • Expired or invalid NDC codes are identified and highlighted
  • Clear reporting on HCPCS codes with policies to ensure correct billing practices for your MAC
  • Ability to load a purchase file which can help your revenue integrity team identify lost opportunities
Get detailed dosage and cost information.
  • Clearly delineated single-dose versus multidose indications enable accurate billing for wastage
  • Pairing of LCD/NCD for specific high-cost drugs to avoid medical necessity rejections
  • Vitalware Billable Units Calculator gives you confidence in the claim’s units of service

Key Benefits for Your Pharmacy Manager

With the right information and an easy to use interface to access it, your pharmacy managers can collaborate and play an important role in assuring accuracy. You’ll benefit from:

  • Backorders and Replacements: Managers can quickly review alternative NDC for back-ordered medications, and assign the replacement in the CDM — ensuring the most accurate NDC appears on the charges sent over from dispensing fields.
  • Benchmarked Pricing: Pricing comparison benchmarks are available for review and analysis.
  • Billable Units: Review of NDC and HCPCS code and cross-map to billing units of service.
  • Single-dose, Multi-dose data is available and can be used in filters for CDM reporting.
  • Easy access to regulatory and payor guidance for high-cost drugs to ensure appropriate billing.

Pharmacy Revenue Issues... Resolved

Pharmacy is one of the biggest expense centers for facilities and the biggest culprits of revenue leakage in a health system. When you use VitalCDM with Pharmacy Analysis, the issues below become a thing of the past.

  • Underpayments due to unit discrepancies in your pharmacy formulary
  • Can’t easily review national and local medical necessity requirements for drugs in your formulary
  • Aren't able to identify revenue codes that are not ideal for the CPT/HCPCS code applied to your medications
  • Can't easily review your pricing against other pharmacy pricing benchmarks, including Medicare peer data and cost to charge percentage
  • Don't receive NDC confirmation of HCPCS code as required for Medicare
  • Don't have workflow and audit history functions to obtain full visibility into the processes surrounding your formulary
  • Can't easily identify compliance risks associated to CPT/HCPCS codes and NDC codes

IMPROVED BOTTOM LINE

Pharmacy continues to represent an ever-greater percentage of overall inpatient hospital costs. Improved data and reporting for pharmacy speeds up billing and ensures hospitals receive full reimbursement for services rendered.

ADVANCED COST METRICS

Just as advanced metrics have revolutionized sports, cost data can radically improve your pharmacy revenue analysis. VitalCDM helps you assess changing acquisition prices, so your team can ensure that your charging-formulas reflect these changes accurately.

COMPETITIVE ADJUSTMENTS

Accurate reports from VitalCDM can help teams with competitive pharmacy pricing, allowing personnel to establish solid benchmarks for current pricing, and compare these against outlined goals and available competitive information.

IMPROVED CONTINUITY

VitalCDM Pharmacy reporting can help your team ensure that all relevant data from the pharmacy system: including National Drug Codes (NDCs), charges, and billable units, are flowing consistently and completely into billing and claims for reimbursement.

IMPROVED COLLABORATION

With reliable reporting, personnel can work cooperatively to decrease errors, and rework missed revenue. The ability to track drugs coming into the pharmacy, their usage in the hospital, and capture the appropriate coding on the claim, enables providers to act on a full spectrum of improvement opportunities.

IMPROVED PLANNING

An detailed assessment of drug usage, costs, and revenue ensures that personnel and financial planning processes are both performing at peak efficiency. VitalCDM with Pharmacy Analysis helps your team establish a firm foundation for planning and decision-making regarding your pharmacy financial practices.

Just One Illustrative Example

The implications of Pharmacy data lagging, both from a reimbursement and compliance perspective, can be enormous. Here's one common example:

J0202 describes alemtuzumab per 1 mg, which is a monoclonal antibody used to treat leukemia, autoimmune anemia, and multiple sclerosis. When used in the treatment of MS, it comes packaged in a 12 mg/1.2 mL vial and it's marketed as Lemtrada. The recommended dosage of this drug is 12 mg per day for five consecutive days, and the current reimbursement per 1 mg is $1,917.04.

That means each day’s dose should be reimbursed at $23,004.48. If, however, one link in the logic chain is wrong — the units for example — and a facility is billing 1 unit instead of 12, they'll lose over $21,000 in reimbursement for five days straight, for just one patient. If the HCPCS code or revenue code are incorrect or the charge never got to the claim at all, the loss may be $23,000 for five days.

Actionable Analysis

Our pharmacy reports assess critical data combinations and alignments for your pharmacy revenue operation. They'll help you analyze core pieces of data and provide guidance for remediation of problems at the data entity level.

See VitalCDM For Pharmacy In Action

Schedule a demo to see how VitalCDM can turn your pharmacy financial operation into a model of efficiency. With our tools, expertise, and your team — you will quickly realize significant and enduring benefit.

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