Building a Pharmacy Revenue Integrity Program

May 2017 - Vol.14 No. 5 - Page #20
Category: Revenue Cycle Management Software

Extending beyond our traditional practice areas to influence strategic and transformative care delivery is within pharmacists’ DNA. Yet, our profession seems to remain relatively content operating within its conventional role. While the value of having a senior-level pharmacy leader at the executive table is undisputed, imagine the possibilities if pharmacy leaders acquired other senior level positions. One opportunity for pharmacy leaders to lean into and work collaboratively with other health system leaders is launching a revenue integrity program.

OhioHealth is a 10-hospital health system with 28,000 staff members, 50+ outpatient locations, and over $3.2 billion in net patient revenue. In preparation for a 2015 electronic health record (EHR) conversion across seven hospitals and numerous physician practice locations, our service line launched a pharmacy revenue integrity program. With annual hospital pharmacy gross revenue for these seven hospitals exceeding $600 million, ensuring proper fiscal management was a significant concern. The initial program goal was to test the hospital pharmacy charge description master (CDM) for coding accuracy and standardize pricing before EHR go-live to minimize post-implementation revenue disruption. The overarching purpose of the financial integrity program is to achieve complete, appropriate reimbursement by driving operational efficiencies and compliant processes.

Development and Implementation Process

The system pharmacy business director was tasked with developing the plan and leading the program’s launch and subsequent expansion. Support from the vice president of pharmacy services, the vice president of revenue cycle management, and robust engagement with finance, nursing, information technology, and compliance leaders was instrumental in bringing the concept to fruition.

Initially, the focus was on ensuring CDM accuracy, standardizing markups, and moving exclusively to charge-on-medication-administration to ensure a smooth EHR transition. All medication charge codes were tested for price, HCPCS, revenue code, and billable unit accuracy. An analytics tool was used to scrub the build multiple times before go-live to identify items not meeting the aforementioned criteria, and thus requiring modification. By importing medication purchase, charge summary, formulary, and CDM data files into the analytics tool, the data is run against embedded algorithms and industry intelligence to highlight risk areas requiring attention. The tool automates quality control processes for efficiently monitoring the correct build of more than a thousand charge codes, creating capacity for the charge analyst to take on additional responsibility.

The success of the financial integrity program is inextricably linked to pharmacy’s ability to engage in an area that is typically beyond the core focus of its service line. The below qualities are instrumental in this pursuit.

Effective Communicator. Pharmacists typically have a temperament conducive to building strong relationships inside and outside the department. Moreover, pharmacists are trained to seamlessly move between physician-focused clinical dialogue and layperson’s terms that facilitate patient interaction. Being well versed in both areas, as well as business vernacular, fosters effective communication with health system leaders. Pharmacists who are relatable to diverse audiences work from a powerful platform to influence change. Excellent communication skills were instrumental to aligning various stakeholders early on in the development of OhioHealth’s pharmacy revenue integrity program and generating momentum for continued growth.

Trusted Advisor. Pharmacists are well-respected professionals. Thus, pharmacy leaders have high credibility when building relationships based on honesty and transparency. These attributes, along with a polished executive presence, garnered approval for implementing a new CDM analytics tool and support for new pharmacy revenue integrity program FTEs. Accomplishing our initial deliverables (ie, ensuring an accurate CDM) opened the door for the team to take on new responsibilities across the enterprise. Trust was the gateway to stakeholder support, defusing any territorial dynamics between various departments.

Problem Solver. Pharmacists enter the profession in part due to a love of mathematics and science. It is not surprising that many are analytical, technologically savvy, intellectual, and decisive. Using critical thinking to identify root causes, pharmacists are often driven to solve complex problems and draw meaningful conclusions. In addition, monitoring for the impact of interventions is hard-wired in most pharmacists, preparing pharmacists to report out measurable results with relative ease.

The pharmacy charge master has inherent complexities compared to the hospital charge master, such as billing unit versus dispense unit considerations, and clinical implications. Pharmacy’s ability to own this space and differentiate between EHR build, designed workflow, and end-user adoption triggers rapid problem diagnoses and resolutions. Addressing issues upstream makes it possible for the team to absorb new work rather than wasting time reviewing recurring charge errors in downstream work queues.

Project Manager. Pharmacists are drawn to continuous process improvement and refine their time management skills early on. A bias toward action, attention to detail, thoughtful planning, and the ability to prioritize help pharmacists accomplish goals.

Defining a narrow scope for our initial goal, focusing on CDM testing, with milestones set ahead of the larger EHR conversion timelines, generated a clear line of sight to our future goals. Single-source-of-truth messaging prevented unnecessary confusion from jeopardizing project completion. Setting realistic expectations with key stakeholders and assessing readiness for change across highly varied care site cultures, well in advance of go-live dates, contributed to widespread adoption and scalable implementation.

Compassionate Sponsor. One reason pharmacists often pursue a career in health care is to help people. Patient advocacy is a common bond among similarly motivated colleagues, lending itself to natural synergy and authentic collaboration.

The pharmacy revenue integrity team’s vision and mission are incorporated into staff meeting agendas, business case proposals, return-on-investment discussions, hiring announcements, on-boarding plans, etc. Connecting the work we do and its value to our patients’ financial experience is vital. Promoting our pharmacy revenue integrity team like a brand, centered on the customers we serve, has translated to consistent service and results despite rapid growth.

The pharmacy revenue integrity program team’s day-to-day activities are split between addressing charge-review work queues and leading process-improvement initiatives. In addition, team members support EHR-related maintenance, review workflows, and attend committee meetings related to maintaining financial integrity.

Maximizing the Program

Post-implementation, the value of having a specialized team centrally supporting hospital care sites prompted additional FTE approvals to extend support into regional care sites, as well as to take on new work (see FIGURE 1). This was in part due to opportunities and gaps uncovered during the EHR conversion preparation, post go-live assessment (see FIGURE 2), and new care site due diligence activities.

Most recently, the team expanded to assist with benefit verification and authorizations for medications administered across eleven hospital-based outpatient infusion clinics. One FTE, a pharmacy charge analyst equipped with a revenue analytics tool, paved the way over a 3-year period to what now consists of 14 FTEs focused on pharmacy revenue integrity across 10 hospitals and three different EHR platforms. The team comprises four pharmacists, three analysts, and seven coordinators.

This diverse group brings unique talents to the program. For example, one team member previously served as a lead technician and drug procurement analyst, while another is a CPA with a Masters in Health Care Administration and a strong financial background. A third team member has experience in health information management. The combined skill set is crucial to solving problems creatively and delivering results.

Lessons Learned

Launching the pharmacy financial integrity program has provided valuable lessons. Throughout the process, we have learned not to underestimate the opportunities that may emerge. When initiating such a program, focusing exclusively on one main goal is an effective strategy for sustainable success. Ideally, one person should take ownership of managing the program. When at least one staff member focuses specifically on financial issues, initiatives are addressed proactively and have less chance of being unintentionally neglected or ignored. Moving forward, we plan to expand the program to include physicians’ offices, home infusion, and specialty pharmacy.

Amidst unprecedented, double-digit drug price inflation, with pharmacy expenses and revenue driving a significant portion of a health system’s overall fiscal performance, extending pharmacy leaders to new areas of the organization can help health systems thrive in a value-based market. A growing number of physicians and nurses have settled into executive roles with broader scope than chief medical officer or chief nursing officer positions; likewise, pharmacy leaders are well positioned and possess transferrable skills to similarly extend beyond our usual space to drive enterprise-wide strategy and outcomes.

Success unraveling the complexity of the pharmacy CDM can be extrapolated to other complex health system challenges. Pharmacy leaders bring a fresh perspective to address issues traditional stakeholders may unintentionally overlook. For those who take the leap, your pharmacy roots will serve as a reliable compass to navigate in new directions.

Tara L. Hanuscak, PharmD, MS, is business director of pharmacy services at OhioHealth, leading a team supporting pharmacy business functions across the organization. In addition to revenue cycle, she regularly collaborates with finance, business intelligence/analytics, and supply chain leaders to drive enterprise-wide value. In 2008 and 2013, she was recognized with the OhioHealth Prism Award for Stewardship, the highest level of recognition for associates who reflect the organization’s mission and values. Tara received her Masters of Science in Health-System Pharmacy Administration and Doctorate of Pharmacy from The Ohio State University.


Like what you've read? Please log in or create a free account to enjoy more of what has to offer.

Current Issue