This product is an ASHP Learning Center https://elearning.ashp.org/ activity.
Accreditation
The American Society of Health-System Pharmacists is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education with Commendation.
Target Audience
This certificate is intended for pharmacists or pharmacy technicians seeking to expand their knowledge and skills in pharmacy revenue cycle management.
Overview
The Pharmacy Revenue Cycle Management Certificate is self-guided, with online learning activities that have been created for pharmacists and pharmacy technicians seeking to expand their skills in managing the pharmacy revenue cycle.
This well-rounded curriculum focuses on the essential and unique skills for understanding the pharmacy revenue cycle, managing the complicated billing process, and using claims data to improve revenue capture and patient care.
The learning activities are designed for participants to increase their knowledge and skills in calculating reimbursement, documentation and billing, Medicare rules and regulations, and revenue compliance and integrity within health systems. Upon completing all the modules, participants should have increased knowledge and skills in navigating regulations and successfully managing the pharmacy revenue cycle for an institution.
Pharmacy Revenue Cycle Management Certificate Requirement
Once a learner has completed the educational curriculum, they will have the opportunity to complete an online comprehensive exam. Once the learner completes the exam (minimum 80% passing rate; unlimited attempts permitted), they will earn the professional certificate.
Educational Activities
Overview Including Cost and Revenue Cycle
ACPE: 0204-0000-25-838-H04-P&T
Application Based
1.75 contact hours
Learning Objectives:
- Contrast the information required to bill a drug on a hospital UB-04 (837I) for an inpatient claim vs. an outpatient claim.
- Assess how at least one U.S. act regulates hospital system billing.
- Apply the correct code set for a pharmacy billing situation.
- Identify chapters in the CMS internet-only manual (IOM) 100-04 (Medicare Claims Processing Manual) that pertain to drug billing in the hospital setting.
- Use the CMS policy / payment information that is posted quarterly.
- Design a list of NDC numbers that are designated as “Unapproved drug for use in drug shortage” in the Food and Drug Administration (FDA) National Drug Code (NDC) Directory.
- Interpret the Medicaid Drug Rebate Program Data to find which NDC numbers are listed with a clotting factor indicator.
Medicare Rules and Regulations
ACPE #: 0204-0000-25-839-H04-P&T
Application Based
1 contact hour
Learning Objectives:
- Differentiate Medicare and Medicaid programs as to which patients are eligible and funding sources.
- Compare the eligibility criteria for each of three groups who are eligible for Medicare.
- Compare your state’s MAC assignments for A/B MACs, Home Health MACs and DME MACs.
- Compare coverage limitation characteristics of Medicare Parts A, B, C, and D.
- Determine which revenue codes crosswalk to the primary cost center of "Drugs Charged to Patients" using the Medicare revenue cost center crosswalk published with each year's OPPS proposed rule.
Medicare Billing
ACPE #: 0204-0000-25-840-H04-P&T
Application Based
2.5 contact hours
Learning Objectives:
- Describe the Medicare outpatient reimbursement model.
- Identify key Medicare rules and policies impacting outpatient billing.
- Evaluate methods for optimizing revenue management in the outpatient setting.
- Describe the Medicare inpatient reimbursement model.
- Identify key Medicare rules and policies impacting inpatient billing.
- Evaluate methods for other service locations in regards to reimbursement and billing.
- Compare various types of billing models used in telehealth pharmacy care.
- Differentiate the code sets for telehealth pharmacy care billing.
Revenue Cycle Building Blocks and Formulary Decision Making
ACPE #: 0204-0000-25-841-H04-P&T
Application Based
2 contact hours
Learning Objectives:
- Define roles and responsibilities of key healthcare and pharmacy revenue cycle stakeholders.
- Discuss the mechanics of the pharmacy revenue cycle.
- Apply resources and methods for ensuring accurate and up-to-date charging for medications.
- Select medications for formulary vs. non-formulary status.
- Differentiate between billing and reimbursement practices for patient home medications and hospital-provided medications.
- Justify situations where the billing of part D is appropriate.
- Outline standard conditions of participation for health systems when caring for Medicare beneficiaries.
Denials, Appeals, Edits, and Calculating Reimbursement
ACPE #: 0204-0000-25-842-H04-P&T
Application Based
2.25 contact hours
Learning Objectives:
- Differentiate between common denial types.
- Outline methods for system pre-bill process changes to mitigate future denials.
- Develop a plan for pre-payment reviews and agency audits.
- Explain CMS billing requirements for drugs obtained through the 340B federal drug pricing program.
- Arrange payment models related to insurance reimbursement contracts.
- Analyze the status of claims based on a remittance advice (RA).
- Develop an appropriate response to a targeted probe and educate (TPE) audit results from your MAC.
Billing for Clinical Pharmacy Services and Collaborative Practice
ACPE #: 0204-0000-25-843-H04-P&T
Application Based
1.25 contact hours
Learning Objectives:
- Describe internal and external key stakeholders when establishing a billable pharmacy service.
- Define incident-to requirements in physician-based and hospital-based clinics.
- Apply evaluation and management CPT code billing rules in patient cases.
- Explain requirements for facility fee billing.
- Apply billing rules and opportunities to various case settings.
Additional Billing Opportunities and Value-Based Care
ACPE #: 0204-0000-25-844-H04-P&T
Application Based
2.25 contact hours
Learning Objectives:
- Design a work plan for pharmacist completed Medicare Annual Wellness Visits in a physician practice.
- Analyze the requirements for billing for Transitional Care Management within a collaborative team in a physician practice.
- Evaluate the components to bill Medicare Chronic Care Management codes in a physician practice.
- Identify other billing opportunities within a physician practice.
- Create an assessment of possible pharmacy initiatives related to value-based care opportunities within a health network.
Using Claims Data to Improve Revenue Capture and Patient Care
ACPE #: 0204-0000-25-845-H04-P&T
Application Based
1.75 contact hours
Learning Objectives:
- Explain how to use publicly available data files to better understand reimbursement calculations.
- Interpret remittance advice data information.
- Analyze charge to cost and reimbursement limits.
- Describe potential reasons for an imbalance between purchasing and billing data elements.
- Assess drug waste billing opportunities and required components.
- Evaluate the potential benefits from merging clinical and financial data points.
Pharmacy Operational Impact and Entrepreneurial Opportunities
ACPE #: 0204-0000-25-846-H04-P&T
Application Based
2.5 contact hours
Learning Objectives:
- Describe methods that exist for charge capture.
- Review the importance of timely and accurate coding and documentation.
- Identify processes that can be used for ensuring integrity of charge generation.
- Analyze current administrative and policy decisions by payers impacting pharmacy operations.
- Review impact of site-of-care changes and plan shifting in the healthcare marketplace.
- Apply principles from part 1 and part 2 of the presentations Pharmacy and Other Clinical Operational Impact to identify charge errors.
- Identify non-pharmacy stakeholders in the revenue cycle process and describe their roles in ensuring appropriate reimbursement for drugs.
- Categorize tasks within revenue cycle that could be delegated to a pharmacy technician under the supervision of a pharmacist.
- Design a comprehensive checklist to identify drug revenue leakage.
- Outline a cross-functional team that integrates pharmacy operations with revenue cycle into an organization.
- Design a job description for a pharmacist who directs revenue cycle management for a hospital system.
Faculty Information
Bradley D. Bruce, PharmD, MHA
Assistant Vice President
HCA Healthcare
Nashville, Tennessee
Megan Dorrell, PharmD, BCACP
Pharmacy Benefits Practice Leader
Apex Benefits Group
Carmel, Indiana
Dina Elberjawi, PharmD
Director, Medical Pharmacy Strategy
Prime Therapeutics
Franklin, Michigan
Suzanne J. Francart, PharmD, MS, BCPS
System Director, Department of Pharmacy
UNC Health
Chapel Hill, North Carolina
Adrianne (Maxie) Friemel, PharmD, MS, BCPS, CRCR
Senior Director, Pharmacy Revenue Cycle Services
Visante
St. Paul, Minnesota
Brody Maack, PharmD, BCACP, CTTS
Associate Professor of Practice
North Dakota State University School of Pharmacy
Clinical Pharmacy Specialist
Family HealthCare
Fargo, North Dakota
Agatha Nolen, PhD, DPh, FASHP
Consultant
Visante
Nashville, Tennessee
Ashley Marie Parrott, PharmD, MBA, BCPS, BCACP
Manager, Ambulatory Clinical Pharmacy Services
Parkview Health
Fort Wayne, Indiana
Grayson Peek, PharmD, MS, BCPS
Senior Director, Adult Clinic Pharmacy Operations
Vanderbilt University Medical Center
Nashville, Tennessee
Farzana Rahman, PharmD, RPh
Corporate Director, Exchange Pharmacy Services
AmeriHealth Caritas
Vienna, Virginia
Bhavesh Shah, RPh, BCOP
Chief Pharmacy Officer
Boston Medical Center Health System
Boston, Massachusetts
Relevant Financial Relationship Disclosure
In accordance with our accreditor’s Standards of Integrity and Independence in Accredited Continuing Education, ASHP requires that all individuals in control of content disclose all financial relationships with ineligible companies. An individual has a relevant financial relationship if they have had a financial relationship with an ineligible company in any dollar amount in the past 24 months and the educational content that the individual controls is related to the business lines or products of the ineligible company.
An ineligible company is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The presence or absence of relevant financial relationships will be disclosed to the activity audience.
- No one in control of the content of this activity has a relevant financial relationship (RFR) with an ineligible company.
As defined by the Standards of Integrity and Independence in Accredited Continuing Education definition of ineligible company.
Methods and CE Requirements
Each activity consists of audio, video, and/or PDFs and evaluations. Learners must review all content and complete the evaluations to receive continuing pharmacy education credit for each activity.
Follow the prompts to claim, view, or print the statement of credit within 60 days after completing the activity.
Important Note – ACPE 60 Day Deadline:
Per ACPE requirements, CPE credit must be claimed within 60 days of being earned. To verify that you have completed the required steps and to ensure your credits have been reported to CPE Monitor, check your NABP eProfile account to validate that your credits were transferred successfully before the ACPE 60-day deadline. After the 60-day deadline, ASHP will no longer be able to award credit for this activity.
The ASHP Professional Certificates SM educational product line contains learning activities that are ACPE-accredited knowledge and application-based continuing education. This is not an ACPE Certificate Program. Upon successful completion of the activities, the learner will be able to download an ASHP Professional Certificate.
System Technical Requirements
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