Direct Billing Workers’ Compensation has been my favorite Non-PBM Revenue strategy for quite some time and can add a much-needed boost to pharmacy profits!
Of the various Non-PBM strategies available, direct billing workers’ comp is often overlooked and, quite frankly, often misunderstood.
Let’s change our mindsets and explore the tremendous profit potential that comes with bypassing pharmacy benefit managers (PBMs) and directly billing workers’ compensation prescriptions.
The Riches are in the Niches
Independent pharmacy is a perfect fit when it comes to workers’ comp, and there are compelling reasons why this niche should be on every pharmacy owner’s radar:
- Tailored Service: Independent pharmacies’ personalized approach and commitment to patient care align perfectly with the needs of this unique patient demographic.
- Profitability: Direct billing workers’ compensation prescriptions can significantly boost your pharmacy’s profitability with very little effort.
- Simplicity: Direct billing with a partner like StreamCare means your patients can serviced quickly, and your employees won’t have to do a bunch of extra work.
Let’s dive into the world of direct billing for workers’ compensation prescriptions and how you can harness this profitable niche for your pharmacy.
The Past and Present of Direct Billing
Over a decade ago, direct billing for workers’ compensation prescriptions was not as streamlined as it is today. Pharmacy owners painstakingly contacted employers and adjusters to piece together the details required to bill for the medications. Thankfully, I had some tenacious technicians to help with this back then!
In those early days, some adjusters granted permission to send bills directly to them, bypassing PBMs. Remarkably, these direct-billed claims yielded significantly higher reimbursements than those processed through third-party PBMs like Tmesys, myMatrixx, and ESI.
Today, direct billing has evolved into a thriving industry, offering pharmacy owners a convenient solution. Companies like StreamCare have streamlined the process, saving time and effort while preserving profitability.
Why I Love StreamCare
StreamCare is one of the leading companies facilitating direct billing for workers’ compensation prescriptions. Their expertise lies not only in simplifying the billing process but also in advocating for pharmacy owners’ rights to direct billing. They understand the profitability of these claims for PBMs and are the most aggressive (IMO) in defending pharmacy owners’ ability to bill directly.
Submitting Claims Is Easy
Processing a claim for direct billing is remarkably similar to handling regular prescription claims. You will receive a BIN from the company you signed up to use. The claim will “adjudicate” show the patient’s copay of $0. Once your biller receives your dummy claim, their team will proceed to create the paperwork to manually send the claim to the adjuster. Very little additional work is required of your staff.
Why Direct Billing Workers’ Compensation Is Profitable
You might be wondering how direct billing for workers’ compensation prescriptions can be so profitable. Is there a catch? The answer is simple: the profit lies in bypassing PBMs. In most states, legislatures determine workers’ compensation reimbursement rates, not PBM contracts. These state-mandated rates often equate to FULL AWP(wow)!
When you bill directly, you receive the full amount permitted by law.
In contrast, when you process these claims through a PBM, you are subject to the terms of your PBM contract. The discrepancy between the state-mandated rate and what the PBM pays your pharmacy is known as the “spread.” PBMs pocket the difference, leaving you with a fraction of the reimbursement.
You Are NOT Increasing The Cost of Care
Direct billing does not result in the state paying more for these prescriptions; it simply ensures that you receive your rightful reimbursement directly. The carrier pays the same rate, no matter if you are sending the bill or the PBM. This option is available to most pharmacies, as approximately 40 states have provisions for direct billing.
Work Comp Patients Find Comfort in Independent Pharmacies
Patients seeking workers’ compensation prescriptions often find themselves in unfamiliar territory. They may not be regular prescription medication users and require additional support and information. Independent pharmacies excel in providing the extra care and attention these patients need.
Injured workers typically experience anxiety about their health, job security, financial stability, and more. Worrying about medication should not be on their list of concerns. Patients feel reassured knowing they are choosing a pharmacy that specializes in serving patients like them. When doctors, nurses, and urgent care centers recommend your pharmacy, it instills confidence in the patient that your pharmacy will handle everything seamlessly.
Direct billing for workers’ compensation prescriptions presents an incredible opportunity for independent pharmacy owners to unlock substantial profit potential. By cutting out the middlemen – PBMs – you can tap into a lucrative revenue stream while providing excellent care to a unique patient demographic. The simplicity, profitability, and patient-centric approach make direct billing an option every independent pharmacy owner should consider.
To determine if StreamCare could benefit your pharmacy, visit this link and fill out the simple form.
Embrace this profitable niche and take a step towards enhancing your pharmacy’s financial stability and patient care.
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