Though we recommend that clinics engaged in pharmaceutical dispensing generally avoid the insurance reimbursement process, we have some clinics that are successfully navigating these rough waters. I recently asked one of our student health centers how their process works.
Q: How does your claims process work for pharmaceutical dispensing?
Clinic: Our claims process is separate from the payors’ routine claims processing. We give our patients a super-bill (receipt) that they can just mail in to the specific address for claims. If the claim has prescriptions on it, our claims administrator forwards it to the payor for processing. Our nurses add NDC code labels (supplied by PCA Pharmaceuticals) that list both the original NDC and the repackaged NDC for the medications prescribed.
Q: Did you have to set up a special claims account with the payor before you started your medication dispensing program?
Clinic: Our arrangement is unique. Our contract was set up through our health insurance broker. We went through a lengthy negotiation process that included college health benefits. As part of the plan, we worked out a process for enabling our students to submit claims for our health services as well as prescriptions dispensed from our health center. Since this plan is offered to all students through the school, we are able to make it seamless to the patient.
The case above is a bit unique because it is a student health center submitting claims on a university sponsored health plan. The key point is that they negotiated a broad contract that encompassed their medical care and dispensing services.
I will continue to look for other examples of the integration of insurance and physician dispensing to share with you in future posts.
