This product is an ASHP Learning Center activity.
Accreditation for Pharmacists and Pharmacy Technicians
The American Society of Health-System Pharmacists is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
Target Audience
This self-paced, online professional certificate is designed for pharmacists and pharmacy technicians who are interested in expanding 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.
Professional Certificate Requirement
Once a learner has completed the educational curriculum, they will have the opportunity to complete a 63-question online comprehensive exam. Once the learner completes the exam (minimum 80% passing rate; unlimited attempts permitted), they will earn the ASHP Professional Certificate.
Educational Activities
Overview Including Cost and Revenue Cycle
ACPE: 0204-0000-23-726-H04-P & T
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: 0204-0000-23-727-H04-P & T
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.
- Distinguish four drug categories where payment is made under Part B or Part D depending upon the drug’s indication.
- 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: 0204-0000-23-728-H04-P & T
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: 0204-0000-23-729-H04-P & T
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: 0204-0000-23-730-H04-P & T
2.25 contact hours
Learning Objectives:
- Differentiate between common denial types.
- Apply strategies to successfully appeal denied claims to a patient case.
- 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: 0204-0000-23-731-H04-P & T
1.5 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: 0204-0000-23-732-H04-P & T
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.
- Propose 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: 0204-0000-23-733-H04-P & T
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: 0204-0000-23-734-H04-P & T
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 how their roles ensure 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 checklist to analyze areas of opportunities where drug charges are not billed on the final claim.
- Construct a grid to track denials and appeals to demonstrate ROI for a pharmacist-led revenue cycle department.
- Design a job description for a pharmacist who directs revenue cycle management for a hospital system.