Pharmacy Profit Niche Worker’s Compensation

pharmacy profit niche worker's compensation streamcare

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Pharmacy profit doesn’t have to be elusive. 

Many proven strategies will help you serve your patients better and increase your pharmacy’s profit. You will need to choose which one(s) to focus on and then go all-in on them to increase pharmacy profit.

One of my favorite pharmacy profit niches is worker’s compensation prescriptions. It is high on my list for a few reasons:

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

Let’s dive into how you can add this profitable niche to your pharmacy. 

It Wasn’t Always Easy

Over 15 years ago, when I was operating my first pharmacy, I received a lot of worker’s compensation patients as we were in the same parking lot as an urgent care (as they say location, location, location!). Inevitably some of these patients didn’t have any information, so we had to dig by calling the employer and then calling the adjuster. These adjusters were local. Sometimes they would say just send me the bill directly. When I did this, I noticed our reimbursements were enormously better than what I was getting through Tmesys, ESI, or any of the online PBMs. 

After many conversations and peeling back the layers of how PBMs really work, I realized that billing directly and cutting out the PBM was much better. I started to do direct billing for all my work comp patients. Not every adjuster was compliant or nice, but many were. And frankly, the adjuster and I didn’t need to be friends. I just needed their billing address and mailbox, and they had to pay the bill. This direct billing was a manual process, and I needed to track my claims and payments. The increased profits were well worth the extra effort. 

It’s Easy Now

Nowadays, a whole industry is dedicated to direct billing workers’ compensation prescriptions. When you use a company, you can remove the burden of paperwork, manually printing reports and mailing bills and tracking all of your claims. You get to save time, process work comp scripts easily, and still make additional profit.

The company that I have worked the most with is StreamCare. I love their onboarding and training process. They are also very tenacious when pushing for your claims to be billed directly. The worker’s compensation PBMs do NOT want to lose these claims (they are very profitable for the PBM). Sometimes, PBMs come out with a vengeance and try to force pharmacies to use the PBM rather than billing directly. StreamCare will fight hard to allow you to continue to bill direct. They don’t win every time, but they win more often, from what I have seen. 

Submitting Claims

Processing a claim for direct billing is almost identical to processing other Rx claims. StreamCare will give you a BIN and a simple process to follow to transmit the data to them for billing. The patient still pays the $0 copay. Once they receive the claim, they get to work on submitting the bills for payment. You can easily track all your claims and reimbursements with their online portal. Much easier than manual reports!

Optimizing Your Worker’s Compensation Book of Business

One more great thing about StreamCare is they will help you optimize your worker’s compensation prescriptions. Because they know the statute reimbursements for each state and how that overlays with costs and their fees, StreamCare can help you optimize for pharmacy profitability. Sometimes, you might be better off billing through a PBM. StreamCare will let you know that. 

Direct Billing Worker’s Compensation Is Profitable For Your Pharmacy

You might be wondering why it is so profitable. Is there something untoward going on? Absolutely not! The profit comes from cutting out the middlemen, PBMs. In most states, the legislature determines worker’s compensation reimbursement rates, not a PBM contract. This state allowed rate is often full AWP (sometimes lower, sometimes higher). You get your full reimbursement amount permitted by law when you bill direct. However, when you bill through a PBM, you get only what your PBM contract allows. 

The difference in these paid amounts is known as the spread. The PBM gets the total amount allowed by the state, but they only pay your pharmacy the small amount they have to. You are getting paid pennies on the dollar while the PBM is pocketing the difference. So when you bill direct, the state is NOT paying any more for these prescriptions than they would if you billed through a PBM. The only difference is you are getting more, and the PBM gets nothing. Direct billing is an option for most pharmacies, about 40 of the 50 states have provisions for it.

Here’s an example of the difference in reimbursements. 

pharmacy profit streamcare work comp

Work Comp Patients Are Best Served At Independent Pharmacies

Many times an injured worker is not taking regular prescription medication. Going to the pharmacy, handing over the prescriptions, sharing information about their employer, and waiting for them to be filled is a foreign experience. I have found that these patients have more questions and need a little more hand-holding than your typical repeat pharmacy customer. I think we can all agree that independent pharmacies are infinitely better at spending time with their patients and ensuring they fully understand their prescriptions and the whole process. 

An injured worker has a lot of fear after they are injured. They are worried about their health, job, family, paying bills, and a thousand other things. Workers should not be concerned about their medications. When patients know they are going to a pharmacy that regularly helps other patients just like them, it puts them at ease. The doctors, nurses, and urgent care centers can let the patient know your pharmacy will take care of everything. The entire process is as painless as possible when they choose to go to your pharmacy. 

To see if your pharmacy could benefit from StreamCare, go HERE and fill out the simple form and Lloyd will get back to you.

If you are interested in more pharmacy profit strategies, be sure to subscribe to our weekly email or YouTube channel. You are welcome to email Dr. Lisa Faast at info@diversifyrx.com.

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