Non-PBM Revenue: The Second Pillar to Pharmacy Profitability

The Second Pharmacy Profit Pillar

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As we continue to work on building a profitable foundation for your pharmacy, let’s dive into our second pillar to pharmacy profitability which is Non-PBM Revenue.

Why Non-PBM Revenue to Increase Pharmacy Profitability?

We all hate the PBMs. Having so much of your pharmacy’s revenue come through a PBM creates uncertainty and anxiety for pharmacy owners. PBMs cause low pharmacy profitability, abusive audits, poor cash flow, negative reimbursements, and many more headaches. Let’s lessen your reliance on the PBMs by growing your non-PBM revenue. 

Previously we talked about Cash-Based Revenues, which are a subset of non-PBM revenue. However, we like to classify non-PBM revenue as pharmacy sales that are not cash-based and are not through a PBM. You might still be billing an entity or waiting on payment for these sales,  but not from a PBM. 

Our goal is to help independent pharmacies grow their non-PBM revenue to 20%. Most pharmacies operate at about 5-10%. This may not seem like much, but it makes a massive difference to your pharmacy profits and cash flow. 

Let’s dive into our some of our favorite top strategies for increasing your non-PBM revenue

Direct Bill Worker’s Compensation Prescriptions

This strategy is one of my favorites. Here’s why:

  1. These patients are best served at awesome independent pharmacies.
  2. It is profitable.
  3. It is easy.

Most independent pharmacies have been running away from worker’s compensation prescriptions for years. These prescriptions weren’t profitable and were riddled with hassles. The juice wasn’t worth the squeeze. 

By eliminating the PBM and direct billing you get to reap the benefits. Most states legislate their work comp rates at the state level. This means the state or insurer pays the same amount regardless if a PBM or a pharmacy bills them. The difference is what you get paid. If a PBM is involved they will keep about 90% of the money. When you direct bill, you get the full reimbursement. 

One of the companies we recommend for helping you with direct billing is StreamCare. StreamCare is very tenacious in helping you with the claims and will fight hard to allow you to continue to bill directly.

There are a few ways to optimize your book of business when it comes down to direct billing for workers’ compensation, and we suggest you take a look at our blog that dives deeper into this.

Direct Bill Hospice Prescriptions

Hospice prescriptions are in a similar situation as worker’s compensation prescriptions because PBMs have butchered the process. I firmly believe that hospice patients, some of the neediest patients, are best served by independent pharmacies. They need fast care and easy access to pharmacists. Independent pharmacies provide that much better than any big box pharmacy. However, pharmacy owners have been running away from hospice prescriptions because of the terrible reimbursements. 

You can work directly with hospice companies and bypass the PBM. Many pharmacy owners are leery about doing this on their own as they just aren’t familiar with the ins and outs of pricing hospice prescriptions. There is a company that can make this easy-peasy, BetterRx. BetterRx streamlines the entire workflow of hospice – from patient to doctor to nurse to the pharmacy. It is like a pizza tracker for hospice prescriptions. Without a PBM involved, you now get paid fairly for hospice prescriptions. Send Ben an email, you can thank me later. 

Pharmacogenetic Testing (PGx)

The future of healthcare is here, and it’s called PGx. Screening a patient’s PGx profile against treatment choices can prevent everything from poor therapeutic outcomes to side effects to even death.

There are several excellent PGx businesses and some that aren’t so great. The distinction is frequently found in how they pay pharmacists and providers. Medicare has modified many of the PGx rules, and there are many opinion letters to assist companies in navigating these changes.

First, you must understand that the labs performing the analysis cannot interpret them. This regulation provides pharmacists with an excellent opportunity to explain the results to the doctor and patient.

Second, you can be compensated for providing a legitimate service. When PGx first became popular, this was a problem. Money was raining down from all directions, and Medicare did not like that. Consulting with providers, and patients and educating are all valid activities that you can be paid for if the test is paid for by Medicare. Many companies operate on a cash basis model as well. 

Our good friend and fellow pharmacy badass, Dr. Jamie Wilkey, is on a mission to help pharmacists get into PGx. You can join a free introductory webinar HERE.

Remote Patient Monitoring (RPM)

Over the last year, RPM has seen a significant boost owing to Medicare’s new regulations, which allow primary care physicians to outsource time-consuming and expensive infrastructure needed when providing RPM services to patients.

Providing value-based care services is the future for Medicare and commercial patients alike. Medicare seems to be seeing value in RPM as they have greatly expanded the number of codes for services. Our friends over at ValueCare Suites have a completely turnkey program to get you up and going and able to collaborate to serve patients. You can get a full update on RPM HERE. 

We believe so strongly in RPM that we have invited Ean Shelley, ValueCare Suite co-founder, to speak at the Pharmacy Profit Summit and walk all the attendees through exactly how to set up an RPM revenue stream. Get your tickets HERE.

Medical Billing

We are in the very infancy of medical billing for pharmacists. This is still being pioneered by several companies and organizations. Medical billing is billing for services to the medical plan, not the PBM. Depending on your state’s scope of practice, you may perform services in your pharmacy or in conjunction with a physician. 

Medical billing can be confusing. It is important that you work closely with your medical biller to ensure you meet the requirements of the CPT codes being billed. I think the most important part of medical billing is your documentation of each encounter. Your notes will help determine what you are able to bill for. 

Getting credentialed and contracted with local plans is not quick and easy. It takes time and effort, just like getting direct PBM contracts. Here are some great companies that can help you get started. 

Medical Billing For Pharmacists Companies

For those wanting to go ALL-IN on clinical services and work very closely with a provider to gain a maximum scope of practice and the maximum allowable codes, I recommend Mobile Mediclaim. They are a one-stop shop and provide everything from A to Z. 

Kandy Morris, the owner of Symplr Healthcare, is a fantastic resource to get credentialed and contracted with local plans. She charges a flat hourly rate (which makes her affordable for anyone) and does provide billing services. Kandy really helps educate you and your staff in this new medical billing territory. You are free to use any EHR or other software in your practice. 

For pharmacies that are looking to bill only Medicare and Medicaid or for just a few basic services, then Electronic Billing Services (EBS) or EnlivenHealth are great resources. 

There are many opportunities to bill medical plans for services depending on your state. 

Clinical Collaboration

Amina Abubakar, a friend, and pioneer of pharmacy innovation has paved the way for clinical collaboration for all pharmacists. Her name is linked with pharmacist-physician collaboration methods in every language.

Embedding pharmacists in offices, establishing collaborative practice agreements, revenue sharing with physicians, and extending pharmacist-led care plans are just a few ways she has created new collaboration models for pharmacies.

Amina established the Avant Institute to assist pharmacy owners in learning the specific actions they must take and offer a framework for support as they expand into this clinical field. If you are ready to jump in and get started, I recommend a call with Ean Shelley from ValueCare Suites.

Lots of Pharmacy Profitability Opportunities Outside of the PBM

Pharmacists have a wide range of opportunities to provide additional services to improve patient care and increase profitability. In this blog post, we’ve looked at several revenue-generating services that pharmacists can offer. Each of these services has the potential to improve patient care and create new revenue streams for your pharmacy.

If you are truly interested in learning how to expand your revenue streams outside of the control of PBMs, then we suggest you join us at the Pharmacy Profit Summit this year. We focus on multiple revenue streams and even have a Bonus Day on August 7th dedicated solely to practical clinical revenue streams.

  • DiversifyRx

    About DiversifyRx

    DiversifyRx is dedicated to helping pharmacy owners kick ass and create profitable, thriving pharmacies. We strongly believe the key to success is diversifying your revenue streams and maximizing each opportunity that is right for you. DiversifyRx was created by a pharmacy owner for pharmacy owners. We offer tons of free information and our Pharmacy Badass University membership. This site contains affiliate links to products or services. We may receive a commission for purchases made through these links.

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