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Details of Pharmacy First Offerings
Member pharmacies may select from a central payment option or direct pay. Pharmacy First offers next-day ACH payment from contracted pharmacy benefit managers via central payment. In either option, we offer full visibility to cash flows via our Member Portal or Mobile application.
Pharmacy First provides member pharmacies with full visibility to DIR fees and primary drivers of reimbursement for every performance-based contract. Member support includes:
- Providing full transparency to contract terms — DIR fee structure, point of sale reimbursement, assessment criteria and collection requirements
- Delivering robust reporting that shows the exact amount of DIR that was assessed on a claim-by-claim basis — Tracking DIR exposure, determining overall profitability and setting DIR estimators
- Facilitating delivery of performance reporting and DIR metrics at the Plan level — Assessing plan level exposure and measuring overall profitability of performance-based plans
- Monitoring individual pharmacy performance and engaging lower performing pharmacies on quality improvement strategies
- Providing access to third party population health management solutions — Bring focus to those patients impacting adherence and other clinical measures used in DIR calculations
- Providing select escrow options for pharmacies wanting more control of their cashflows
While we have been addressing issues with DIR fees and reimbursement below cost for a long time, Effective Rate Contracts are another challenge that can leave pharmacies underpaid.
To protect our members, Pharmacy First created a selective escrow process to capture overpayments so when a true-up occurs, we will be in position to protect those pharmacies that are consistently underpaid. Escrowing is the right thing to do for our member pharmacies that need that safety net to stay financially and operationally successful.
Central or Direct Pay Reconciliation - Customized Solutions
Pharmacy First reconciliation service is designed to accommodate central or direct pay arrangements. In a central pay model, payments are sent directly to Pharmacy First along with a 835 electronic remittance file for fast reconciliation. A direct pay model has payments flowing to the pharmacy.
In either arrangement, Pharmacy First has a solution to meet your needs. Our reconciliation service can be combined with our Contracting services as part of our Premium Membership package utilizing central pay or can be implemented in conjunction with direct contracts. Either configuration allows you to use our secure data platform to efficiently manage your receivables.
Pharmacies can also rest assured knowing that we are working to recover every penny due on every claim. Our comprehensive, customizable solution fits the needs of single store operators to multi-store small chains looking to efficiently manage the complexities of pharmacy claims reconciliation.
Pharmacy First offers a MAC Appeals tool to submit and track MAC appeals using our streamlined, automated process. Members can use our tool to find information about NDCs that pharmacies are currently losing money on, and appeal to the third-party payer for a reimbursement adjustment.
We provide a MAC adjusted product list that shows Pharmacy First’s successful MAC Appeals, and the top NDCs that Pharmacy First is currently working on appealing.
Medication Therapy Management
Pharmacy First provides access to several Medication Therapy Management platforms as required by individual payers. These platforms serve opportunities for targeted interventions and comprehensive medication reviews which many also impact the DIR fees assessed under performance-based plans. Our clinical team provides direct support in getting pharmacies set up on the platforms and are available to help with operationalizing a MTM program within the pharmacy’s daily workflow. Our team also continually monitors pharmacy level performance and revenue opportunities to help drive yearly completion goals.
Pharmacy First recognizes the benefit of implementing an Adherence focused workflow – Not only is there a direct impact on improved patient outcomes, but there is also a corresponding increase in revenue and overall patient satisfaction. Our partnerships include solutions that provide direct visibility to Adherence measures through our Performance Suite set of tools. Applications, such as EQuIPP, allow pharmacies to isolate patient outliers for additional engagement. We also offer a suite of services through CSS Health to help pharmacies implement an appointment-based practice, including medication synchronization workflows, adherence packaging and clinical intervention documentation tools.
Pre- and Post Edit Program
Pharmacy First provides Performance Suite, a robust pre-post edit program in order to help members improve their reimbursements and streamline their workflow. Performance Suite, reviews every claim in real-time to ensure correct processing and pricing. The program also provides valuable reporting to ensure financial, operational and legal compliance.
Through the Pharmacy First Performance Suite, claims are automatically reviewed for savings at the point of dispense. Reducing patients' out-of-pocket prescription costs directly impacts first fill abandonment rates and promotes ongoing compliance — Enhanced adherence drives better outcomes and lower DIR fees.
Pharmacy First collaborates with both the PBM and the pharmacy to monitor audit risks and educate members on potential audit concerns.
Reporting and Compliance
Pharmacy First’s prestigious URAC accreditation as a Credentials Verification Organization (CVO) signifies commitment to quality healthcare, efficiency and compliance through rigorous credentialing. The URAC accreditation process demonstrates a commitment to quality services and serves as a framework to improve business processes through benchmarking organizations against nationally recognized standards.
To achieve and maintain URAC accreditation, Pharmacy First’s credential verification process goes beyond the norm of simply validating whether a pharmacist is licensed. The licenses and credentials of each pharmacy and staff member is verified in the same manner, testifying to a high level of excellence throughout the entire organization. The focus on the pharmacy as a whole – including its process, operations and integrity – ultimately translates to better, safer care, which can improve patient outcomes and experiences.
As part of the commitment to quality and ongoing compliance, Pharmacy First provides a robust member portal for program-related support and ongoing communications, freeing pharmacists to nurture their patient relationships and make a bigger impact on community health.
Pharmacy First maintains a conservative approach to contracting that is driven by the principles of the independent pharmacies within the network. Contracts are constructed with direct input of pharmacy owners throughout the network and based upon operational analytics across 2,200+ pharmacies. Revenues are enhanced by reducing exposure to preferred cost-sharing contracts and working with member pharmacies to gain access to plans that maximize profit.
With the rapidly changing healthcare environment, pharmacies look to differentiate themselves with new services and offer value to their patients. To support these efforts, Pharmacy First actively engages payers and pharmacies on creating new revenue streams outside the typical dispensing framework — MTM Revenue, vaccine administration, preventative services, lab testing, pharmacogenomics and prescriber collaboration.
Our Cash Claims Management program gives pharmacies control of cash pricing, allowing them to offer patients competitively, consistently priced medications — as well as a $4 generic program — to compete with larger chains. And our rebate programs bring our members manufacturer-sponsored rebate checks to improve their bottom line with no disruption to daily workflow.
Supporting the Quality and Independence of Community Pharmacies in an Evolving Market
Read the guest blog post from Pharmacy First to learn how this PSAO has set the highest standard in the industry as the first and only PSAO to earn URAC accreditation as a Credentials Verification Organization.