Increasing your Non-PBM Revenue is a great way to increase your independent pharmacy’s profits.
We all detest the PBMs. So, let’s focus on decreasing your dependence on them by increasing your non-PBM revenue.
Having a significant portion of your pharmacy’s revenue tied to a PBM introduces uncertainty and anxiety for pharmacy owners. PBMs contribute to low pharmacy profitability, abusive audits, poor cash flow, negative reimbursements, and numerous other headaches.
Let’s reduce your dependency on PBMs by expanding your non-PBM revenue streams.
Our goal is to help independent pharmacies increase their non-PBM revenue to at least 20% of total revenues. Currently, most pharmacies operate at around 5-10%. Although this may seem modest, it can significantly impact your pharmacy profits and cash flow. Not to mention how well you sleep at night!
Let’s explore some of our top strategies for boosting your non-PBM revenue.
Non-PBM Revenue Tactic #1: Direct Bill Worker’s Compensation Prescriptions
This strategy is one of my favorites, and here’s why:
- These patients are best served at exceptional independent pharmacies.
- It is profitable.
- It is easy.
Many independent pharmacies have avoided worker’s compensation prescriptions for years due to unprofitability and hassles. By eliminating the PBM and opting for direct billing, you can reap the benefits. Most states legislate their work comp rates at the state level, meaning the state or insurer pays the same amount regardless of whether a PBM or a pharmacy bills them. The difference lies in what you get paid. If a PBM is involved, they retain about 90% of the money. When you direct bill, you receive the full reimbursement.
We recommend StreamCare for assistance with direct billing. StreamCare is dedicated to helping with claims and fighting to allow you to continue direct billing. You can be up and running in less than an hour! It’s easy, it’s profitable, and you can thank me later!
Non-PBM Revenue Tactic #2: Direct Bill Hospice Prescriptions
Hospice prescriptions are similar to worker’s compensation prescriptions because PBMs have complicated the process.
Hospice patients are among the most in need and are best served by independent pharmacies. They require fast care and easy access to pharmacists, which independent pharmacies can provide much better than big-box pharmacies. However, poor reimbursements have driven pharmacy owners away from hospice prescriptions.
You can be fairly compensated by working directly with hospice companies and bypassing the PBM. Many pharmacy owners hesitate to do this alone due to their unfamiliarity with pricing hospice prescriptions.
Have no fear; BetterRx is here!!
BetterRx can simplify this process, streamlining the entire workflow from patient to doctor to nurse to pharmacy, similar to a pizza tracker for hospice prescriptions. Without a PBM involved, you can now be fairly compensated for hospice prescriptions. Contact Ben at BetterRx, and you can thank me later for this one, too.
Non-PBM Revenue Tactic #3: 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 poor therapeutic outcomes, side effects, and even death.
I truly believe that every patient taking medication should have a PGx profile, and pharmacists, along with independent pharmacies, are best suited to provide this service.
There are many PGx companies out there. Here are some of our favorites:
- OneOme – great full-panel option
- Fagron Genomix – fantastic tests, but don’t let pharmacists independently order all tests (ugh!)
You don’t need any special certification to help your patients with PGx. Your pharmacy degree, expertise, and ability to interpret reports are ALL YOU NEED!!! Don’t be fooled into spending more time and money and waiting to start your program.
Non-PBM Revenue Tactic #4: Remote Patient Monitoring (RPM) & Chronic Care Management (CCM)
Over the past several years, RPM has seen significant growth due to Medicare’s new regulations, which allow primary care physicians to outsource the time-consuming and costly infrastructure needed for RPM services. RPM, CCM, RTM, TOC, and other acronyms continue to save Medicare and Medicaid money in the long run as they expand access and service codes.
If you haven’t jumped into this pool, NOW IS THE TIME!
We strongly believe in RPM and CCM for our members that we offer monthly support calls with one of the leading experts in these services, Ean Shelley. Ean is a founder and leader at ValueCare Suite. They have amazing software that makes providing and tracking all these services as easy as possible. These services are unique because you MUST use software of some type to track the readings and time in order to bill. You might as well use the best!
Several of our members have seen astronomical success with these programs. Adding between $5,000 to $60,000 a month in profits.
Non-PBM Revenue Tactic #5: Medical Billing
We are still in the early stages of medical billing for pharmacists. This area is still being pioneered by several companies and organizations. Medical billing involves 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’s crucial to work closely with your medical biller to ensure compliance with the requirements of the CPT codes being billed. Proper documentation of each encounter is key to determining what you can bill for.
Getting credentialed and contracted with local plans is neither quick nor easy. It requires time and effort, similar to obtaining direct PBM contracts. Here are some excellent companies that can help you get started in delivering clinical services and being paid for them. (In no particular order)
Medical billing for pharmacies and pharmacists is the future. While opportunities are just beginning to emerge, they will get bigger and wider with time. We will be devoting a significant portion of our Pharmacy Profit Summit 2025 to practical and effective medical billing. If this is an area you want to implement, there is no better place than PPS 2025. Learn more about our upcoming summit and get your ticket before we are sold out (at the time of this writing, over 50% of tickets are sold with 9 months to go).
Lots of Pharmacy Non-PBM Profitability Opportunities
The above tactics are just a fraction of the non-PBM revenue opportunities available for independent pharmacy owners. It can be hard to stay on top of opportunities, tactics, and foundational knowledge to maximize your pharmacy’s performance. We can support you as a member of Pharmacy Badass University. Check out membership HERE. We also offer tons of FREE resources available to everyone. You can access those from our main website HERE.
