Are You Capturing Every Medical Billing Dollar Available to Your Pharmacy?

Shannon Battle 0:10

We got a few more people rolling in here, but good afternoon and welcome all of our IPC members and viewers. I do want to take the time to thank you all for, you know, giving us a few minutes out of your busy schedules. We really are excited to dive a bit deeper into some really eye-opening medical billing information today. So

Today I want you to ask yourself, am I currently medically billing everything possible? Am I capturing every single dollar that’s available? And what opportunities are really still on the table out there? For those of you who don’t know me, my name is Shannon Battle. I am the Pharmacy Services Manager here at IPC and your primary point of contact for all of our vendor partners.

A little housekeeping before I introduce our guest speaker. At the bottom of your screens, or maybe to the side, you all will see a Q&A section in chat. We are going to have that open, but we’re going to save those discussions for the end of the presentation, just to be respectful of everyone’s time during the day. You are welcome to drop any questions or comments in there, and the recording and the Q&A will be sent out afterwards to all of our registrars.

So today I am joined by Rachael Matz. She is Head of Clinical Solutions at DocStation. Rachel, you are a powerhouse of information in this space. I know you are going to have some fresh perspectives on billing, some things that, you know, as technicians and pharmacists, we are so accustomed to doing things the old way.

We bill everything to Part D, we get a rejection to bill it to Part B, and we pray to whoever is available that we have that information available. And that’s just not the way it should be anymore. You know, we have to be much more educated. We have to know what’s out there and use the resources that are available for us. So thank you again, Rachel, for being here. I am excited to hear what you have for us today.

Rachael Matz 1:59

Love it. Thank you. Thank you. I really appreciate the opportunity. My background is actually in education. So I do not have a pharmacy background by trade, but it is something I’m very passionate about. I love being able to educate. I love being able to get up in front of people. So if it sounds like I have my teacher hat on, sometimes I’m so sorry. It’s hard to take it off.

I have been out of education for almost 10 years, but it’s just, it’s hard to sometimes separate that. So if it does sound like that, I apologize. But I think, yes, we have a really good kind of opportunity for some quick education. I think that this is really going to resonate a lot with pharmacies, pharmacy owners.

Shannon Battle 2:27

It is, yeah.

Rachael Matz 2:41

students, technicians, pharmacists alike. And things have been a certain way for so long. And so I’m hoping to be able to challenge some of those ideas, challenge some of those concepts of what you’re used to. And it might make you a little uncomfortable, but that’s okay. It’s supposed to be uncomfortable to start with. And then the trade-off is worth it.

And so just give me a couple of minutes. I promise it’ll make sense. But I do want to encourage any questions that you guys have. If you want to drop those questions, leave it. I promise I’ll get to them. But any questions you have throughout the presentation, go ahead and drop them in the chat or in the Q&A, because we’ll be able to address those as well. So bring any tough situations, ideas, anything like that. I’m happy to answer the hard questions too.

So what I always try to start off with is helping folks, if you don’t know, or even if you do have some sort of idea of what medical billing is, really kind of diving into a quick background on the difference between pharmacy billing and medical billing. And you’re used to doing, pharmacies are used to doing prescriptions all day, every day.

right? So when you bill through your dispensing software and you’re billing through using NDC codes, you’re being reimbursed by the PBMs, right? And so your margins there and everything that you’re being reimbursed is through the PBMs through that prescription insurance. These are going to be products like lisinopril.

like metformin, like your different antibiotics, things like that, that you’re going to bill to your prescription insurance. The medical side here is when you’re billing through, yes, your medical billing software, it can originate through the pharmacy dispensing software, but you must have a separate software that allows you to bill

medical claims. These are not going to be prescription claims. These are going to be medical claims. So even if you are used to seeing your vaccines go off and you’ve crossed your fingers and hope it gets paid, when you submit that flu shot for your Medicare patient, it’s a medical claim. You’re already medically billing. And I’m going to talk about some of those differences and nuances as well. But those claims are going off as a HCPCS code, as a CPT code. You’re not billing around an industry.

DC, you are billing around a medical claim and medical codes.

So you’re being reimbursed by plans like straight Medicare Part B, a Medicare Advantage policy, a commercial or Medicaid payer. But these are medical reimbursements. These are not prescription reimbursements. So big difference there. Some examples might be, again, things like vaccines, CGMs, testing supplies, things like that.

you’re probably already billing a lot of those for your Medicare population as it is today. So that’s just a general background and kind of again, hammering that point home where you’re probably already billing medically, but you may not really fully understand the benefits of doing so. Things like vaccines,

NEB Solutions, your CGMs, any other DME equipment, all of those for your Medicare population, you are already billing those claims medically. So everything that’s going off as a CMS 1500 form, that’s already a medical claim. You’re doing that. It may be through your dispensing software, but you’re already billing medically for it.

Okay, so this isn’t necessarily a new concept. It might just be a little bit of a retraining your brain on how to think about it. Now, where we come in is asking the hard questions. Are you actually capturing every dollar that you could be? And in particular, when it comes to vaccines, I think this is a really relevant topic, especially because we are

obviously coming up into vaccine season. But one of the things that I want to challenge you on, and anybody that’s listening to this later on or live on the call with us, are you actually billing everything medically that you could be? So most pharmacies today really only see two options when it comes to billing your vaccines. For Medicare population, you’re usually billing to the Part D plan, as in Delta, or B as in boy.

That’s pretty much all pharmacies ever see. There is a third option, and this is a Medicare Part C plan. And it’s a Medicare Advantage policy. For so long and for so many pharmacies, when I say the word advantage or advantage plan, pharmacies immediately default to a prescription benefit. And that is not the case. When you hear advantage policy,

you should be thinking, does this patient have medical benefits through that advantage policy? And so what we are able to identify through DocStation software is if that patient has a part C coverage, which means or it entails medical benefits through the advantage policy, we can find those coverages.

and allow you as the pharmacy to build to those medical coverages, those medical policies. So an example down at the bottom, I like to pick on Optum because they’re easy to pick on. But let’s say last year you had a patient come in for a flu shot, high dose flu vaccine might, Optum might pay you what, $100, 101 on a good day.

for a high dose vaccine or high dose flu, excuse me, they are not going to pay you an incentive fee. You can put it in Pioneer or PrimeRx or Computer-Rx all day long as an incentive fee. Optum is not going to pay you an incentive fee. That same patient that has Optum Part D as in Delta, that same patient has medical coverage through UnitedHealthcare.

Guess who pays that incentive fee?

UnitedHealthcare pays that incentive fee. And you as the pharmacy should be billing that vaccine to UnitedHealthcare. You will be making $25 to $35 more through United than you ever would through Optum. And it’s because you as the pharmacy have the ability to bill to that Medicare Part C.

benefit. You can build to UnitedHealthcare for that Medicare patient and you can make more through United than you could through Optum. So again, it might be a new concept. It might be something that you’re not quite used to and maybe a little uncomfortable, but you can build to UnitedHealthcare and you would be making more through United than you ever would through Optum.

Kate.

So the big question is, you know, what does it do for me? Why is this matter? Okay. It matters because of the additional revenue that you stand to make. And you’re more than welcome to, you know, snapshot this. I can send out this presentation later as well. But this is a lot of data on the screen. But one thing I want you to take away that these are real claims that were submitted through

doxation software last year in 2025. This is roughly a little over 20,000 claims or so, but I want you to notice this is for Medicare population. These are not shingles, Tdap, RSV, you know, vaccines. These are for your Medicare population. Okay. So looking at your patient population,

What additional dollars do you stand to make by being able to bill to a medical policy?

And in some cases, it’s quite significant, right? So anytime you have the ability to bill medical, our goal at DocStation is to get you the equivalent or as close as we can to the equivalent to that Medicare Part B fee schedule. We want you to be making the Medicare Part B fee schedule for any Medicare patient.

We want you to not have to make the PBM fee schedule, right? We want to get you the opportunity to make that additional revenue through the medical policy. And that’s the trade-off.

Shannon Battle 9:58

You know what, you know what stands out here to me, Rachel, is that we know some of our stores are very high, you know, producing when it comes to vaccines. I mean, they are doing 500 to 1000 a piece. And you’re telling me this is 20, a little over 20,000. I mean, if you’re doing 1000 vaccines in your store throughout the course of the season, that is a huge chunk of this $1,000,000 that’s being

missed. I mean, this is not an overinflated number for thousands and thousands of pharmacy. You could have 10% of this, you know, or, you know, a very large percentage based on, you know, what your book of business looks like. So these numbers are very real. I love to see this.

Rachael Matz 10:37

Yeah, it’s real data. It’s not, you know, manufactured data. This is, these are real doxation claims. And so we’re really trying to, one, just educate, get the information in front of people, because it is not a common concept, right? It is not a common thing to hear advantage and think medical.

You hear advantage and you think prescription. And I want to really challenge that concept and I want to make sure that folks understand that there is a different way to do things.

So yeah, it’s definitely fun to be able to kind of go through the data and pick it through for sure. Now I do get questions all the time. What do I have to do in order to be able to do this right? One, you have to have the right NPIs, right? You’ve got to have your type 2 NPI. You’ve got to be able to, you know, bill medically.

If you are already billing or already enrolled as Medicare as a supplier for either vaccines, mostly for vaccines to get that mass immunizer PTN, you’re good to go. That is what you need. If you do not have a mass immunizer or an 855B as in boy PTN, you need to go get one.

I don’t have another way to sugarcoat that one. If you cannot bill Medicare for vaccines today, you need to be doing that. You are losing revenue for every Medicare patient. If you are billing to the Part D benefit, you’re losing out every time. It might be easy. And I know that it’s, you know, an instant gratification because you get paid.

right? You know how much you’re getting paid. You see it right there on the screen. Medical is not the same way, right? Medical is not going to get you an instant adjudication for a claim. It does take several weeks because it’s a medical benefit. But the revenue, the extra revenue that you stand to gain, if you do not have an 855 BPTM, you’re losing money.

And there’s no way around that one. There’s no way to sugarcoat it. Go get an 855B as in boy, PTAN. Being able to learn the billing codes. This one is, yes, important, but at the same time, you should also have access to a medical software. So DocStation is a medical billing software. You should have access to one that will help you with those codes. I do not need pharmacies to come in knowing how to bill a vaccine.

I don’t. You do not know, you don’t have to know how to build a, you know, a HCPCS or a CPT code. We will, one, either teach you, you know, from your dispensing software to help you go through and do that, but two, we map all of those codes for you. So I, real example, I ran across a pharmacy last week.

who has a medical biller that every week they’re going manually one claim at a time into Noridian and billing one claim at a time.

Please don’t do that. You don’t have to. I mean, there’s really no reason that you should ever have to do that. You do not need to know what CPT codes to bill for a flu shot versus a COVID shot, right? All of those are embedded in here. It’s important to know the difference for sure, but you don’t have to know the individual codes in order to be successful in billing.

And then of course, you do need a dedicated software. If you are billing Part B today, you have a software. Whether you recognize it or not, you’re on Doxstation, you’re on Transact, you’re on Omnisys, you’re on FDS Midbill. There’s a lot of them out there. I get it. But at the same time, there’s not a whole lot of systems out there that are going to do what we do and be able to help you identify your gaps.

and help you understand what you’re missing. If you’re just billing part B&D only, you’re missing revenue. There’s no two ways around it. If you are only billing B&D, you’re missing out. So you do need a dedicated software that will not only identify the gaps for you, but you have to have somebody that’s going to be able to submit a medical claim.

So that is where DocStation would be a really good fit for a lot of pharmacies that are looking to make that additional revenue this year.

So kind of leading into that as well, we are built for that, whether you are just looking to make additional revenue in vaccines, or if you have the potential to submit more than vaccines. So DocStation at its core is a medical billing software for pharmacies to be able to let you submit any type of medical claim.

not just vaccines, not just DME, but you can submit consultation claims. You can submit DSMES, you can submit DPP. I know I’m throwing around a lot of acronyms, so, you know, if you don’t know them, you know, shout it out. But you can bill any medical claim that you need to through our software, not just product.

Now, along with that, you do have to have some sort of dedicated software to be able to document those encounters. So if you are looking to expand your services, point of care testing, if you’re looking to get into consultations, if you’re looking to get into diabetes classes, you not only have to have a medical billing software, you have to have a dedicated platform to

log your encounters, to schedule an appointment for a patient, to be able to bill a secondary claim for a patient, especially around DME products. So our platform not just allows you to bill for vaccine claims, which is great, but you now have a system that’s going to grow with you and expand into other services that you can also grow into as well.

So it’s not, again, just a singular platform for vaccines only. We do have a lot of other opportunity for expansion in that space as well. So important to make that distinction there for sure.

Shannon Battle 15:57

It is. I’ll say the, you know, the added benefit of the DME and the other clinical programs and everything that could potentially be medically billed, you know, is outstanding. We have so many stores this year, you know, worrying about reimbursements to where they’re now building out their cash programs in store, which includes all of this consultation.

Rachael Matz 16:15

Yeah.

Shannon Battle 16:17

all of these point of care testing. And you’re inevitably going to get a patient that says, well, I want to bill it to my insurance. And if you already have this in place, if you’re already familiar with it, that is just chef’s kits to be able to add that on and say, well, yes, I can bill it as well. And your staff does not have to know every single CPT code. They don’t have to know all of that if it’s not something you typically do.

The templates and the platform in general is just absolutely perfect for training an entire staff on things where we typically only have maybe one pharmacist or one technician that’s really aware of that and taking care of it all.

Rachael Matz 16:53

Yeah, I’m actually so glad you mentioned cash pay services too. I think that it’s important to make the distinction between what you are collecting in the pharmacy space versus what you’re collecting clinically. And a lot of times pharmacies only have one point of sale system to be able to charge patients, whether that’s again for a clinical service

or a pharmacy-based service for a prescription. What DocStation has the potential to do is let you separate those two so you, from an accounting perspective, can really understand what are you making clinically and what are you making on the prescription side. And so DocStation has tools in place that you can build a patient directly from DocStation. So if you already have a cash pay system in place,

but you’re looking to really fully understand what you’re truly bringing in revenue-wise, you can separate those pieces out and you can build a patient directly from here as well. It works really well for those cash-based products and services too. So I know I’m right at that 20 minute mark, so I’m gonna take a step back for a second. There is an opportunity, so if you would like more information, if you would like to chat,

Shannon Battle 17:47

Okay.

Rachael Matz 17:58

Super quick, easy way just to fill out a couple pieces of information. Even if you’re not, if you don’t know if you’re ready, I still want the opportunity for us to chat, right? I still want to, you know, have a conversation. Tell me where you’re at. Tell me what you’re doing today. Let’s see if this is a good opportunity to implement now. Do you need to, you know, do a couple of things first before you’re ready to do that?

Do you have a PTN? Are you ready to go? All of those questions, I don’t want you to feel like you have to answer alone. Come in, even if it’s just for a quick 10, 15 minutes. Come and chat with somebody so that we can kind of tell you and help direct you where you need to go. So that’s up there on the screen. More than welcome to scan that and have the opportunity to come and chat with one of us as well.

Shannon Battle 18:38

Yeah, I think that’s really important, you know, as pharmacy owners and just business professionals in general, it’s hard to make that jump to the next program, to the next thing we need to implement. You have to worry about all of the staff training, all of the follow up, you know, what is this really going to take for me to implement in my pharmacy?

or to make better what I already have. And I think just that that quick conversation, like you said, identifying, is this going to work? What are the opportunities that I really have? And if it’s not, that’s okay. It gives you those little ideas that lets you know, you know, what the ask really is going to be or what the lift really is going to be in your pharmacy. And I think those short conversations are absolutely necessary.

Whether you think you have it ready or not, or if you think, you know, your staff is perfect at this, I don’t need an additional program, but let’s talk about it. What are you doing already? Is there that aha moment or that one thing that may make a difference, you know, with your staff or training?

Rachael Matz 19:34

Absolutely. Yep, that’s what it’s about. So feel free, please use that. I know we didn’t have any questions come into the chat, but I am happy to answer any questions. If anybody has any tough scenarios, tricky questions, I’m all ears. So feel free to type something in if you want to.

You’re more than welcome to that.

Shannon Battle 19:55

Absolutely. Well, I know, you know, middle of the day, everyone’s probably behind the counter and helping all of the patients with back to school coming up and all of that. But like Rachel said, the QR code on the screen will take you to IPC’s landing page for DocStation where you can fill out the short lead form there. They can give you a call and just, you know, do a quick review with you, see if it’s something that’ll work and what benefits you guys may or may not use.

Rachael Matz 19:59

Yeah.

Shannon Battle 20:18

Again, definitely go back and ask yourself those questions. You know, am I doing everything to its fullest capability? You know, do I need assistance with anything? You know, time is ticking, like she said, on the contracting and the payer credentialing. Some of those things do take some time. So we are on the straight away through the end of the year. And whatever you have set up at your pharmacy now, or

you know, pre to say, maybe October is what you’re going to have well into next year. So you want to make sure that it’s something that’s effective for your pharmacy and going to bring in the revenue that you need. So.

Rachael Matz 20:50

Yep.

Shannon Battle 20:50

Thank you everyone again for attending today. I don’t think I’ve seen any questions come through, but definitely feel free to send us any after or add it to that contact form again on IPC’s landing page for DocStation. And Rachel, thank you again for being here.

Rachael Matz 21:03

Absolutely, it’s not a problem. Thank you for the invite. I appreciate it.

Shannon Battle 21:06

Have a great day!

Rachael Matz 21:07

Thanks, everybody.