Retail · Specialty · Long-term care · 340B

Pharmacy billing that holds on to the margin you already earned

Your pharmacy dispenses the script, absorbs the acquisition cost and then waits to find out what it actually earned. We work the claim at the counter, chase the reversals and authorisations that quietly go uncollected, and reconcile every fill against what the plan really paid so DIR fees and clawbacks stop arriving as a surprise.

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Common billing challenges

Reversals that never become re-bills

A prescription is reversed at the counter and never re-submitted once the issue clears. Each one is a filled script with no revenue against it, and because the claim was reversed rather than denied it never appears in a denial report. We track reversals as open work until they are re-billed or deliberately closed.

DIR fees absorbed as write-offs

Direct and indirect remuneration fees arrive weeks after the fill, often netted across a batch. When they are posted as a lump adjustment the real per-script margin is invisible. We separate DIR and clawbacks from payment so you can see which drugs and which plans are losing money.

340B duplicate discounts and split-billing errors

Covered entities carry real exposure if a 340B claim is also rebated through Medicaid, and contract pharmacy arrangements make the determination harder. We maintain the eligibility logic and keep the reporting an audit expects.

PBM audits answered from scratch

A desk audit asks for signature logs, prescriber verification and invoice trails on specific claims, usually with a short deadline. Pharmacies that assemble this reactively lose recoupments they could have defended. We keep the documentation attached to the claim as it happens.

Specialty prior authorisations abandoned mid-process

High-cost specialty fills stall waiting on a prior authorisation, and the patient goes elsewhere or goes without. We own the authorisation through to an approval or a documented denial, with the clinical information the plan actually requires.

Compounded claims priced incorrectly

Compounds bill per ingredient against quantities and units that must match the formula. A single wrong unit converts a payable claim into a reject or, worse, an overpayment that gets recouped later with interest.

From first verification to final report.

01 Intake review of your dispensing system, switch, PBM contracts and 340B status
02 Baseline on reject rate, reversal volume, DIR load per plan and days to payment
03 Eligibility and formulary verification before the fill where the plan supports it
04 NCPDP claim submission with rejects worked in real time at the point of sale
05 Drug utilisation review exceptions reviewed, resolved and documented
06 Prior authorisation submitted and chased to a decision for specialty and non-preferred drugs
07 Reversals and partial fills tracked as open items until re-billed or closed
08 Remittance posting from 835s and PBM statements, with DIR and clawbacks itemised separately
09 Patient cost-sharing calculated and communicated in writing
10 340B split-billing determinations and duplicate-discount reporting maintained
11 Monthly reconciliation of fills dispensed against fills paid, with exceptions listed by cause
12 Audit documentation assembled and retained per claim, ready before a request arrives

Pharmacy billing FAQ

Is pharmacy billing different from medical billing?

Substantially. Pharmacy claims go out as NCPDP transactions through a PBM switch and adjudicate in seconds at the point of sale, where medical claims go out as 837P and take days. Pricing runs against a formulary with DIR fees applied after the fact. The skills, the systems and the failure modes are different, which is why we staff it separately.

Do you work inside our existing pharmacy system?

Yes. We work in your dispensing platform and switch rather than asking you to move. If you run both a pharmacy and a clinic we can cover the medical side from the same team, but the pharmacy work is handled by people who do it daily.

Can you handle 340B contract pharmacy arrangements?

Yes, including split-billing determinations, duplicate-discount prevention and the reporting a HRSA audit expects. We will tell you plainly if your current arrangement has gaps we can see.

What about long-term care and specialty pharmacy?

Both are supported. LTC brings cycle fills, per-diem arrangements and facility billing; specialty brings prior authorisations, limited distribution and high-dollar claims where a single reject matters. We handle each on its own terms.

How quickly can you start, and what do you need from us?

Usually two to three weeks from signed agreement. We need read access to your dispensing system, your PBM contracts, and a recent remittance sample so we can baseline reject and DIR behaviour before changing anything.