Establishing a pharmacy revenue integrity team: A blueprint for increasing pharmacy’s role in health-system revenue cycle

Abstract

Abstract Purpose An increasing focus on driving margin has pushed health-system pharmacy departments to find new ways of generating new or protecting existing revenue. At UNC Health, a dedicated pharmacy revenue integrity (PRI) team has been operating since 2017. This team has been able to significantly reduce revenue loss from denials, increase billing compliance, and improve revenue capture. This article provides a framework for establishing a PRI program and reports results generated from it. Summary The activities of a PRI program can be grouped into 3 main pillars: minimizing revenue loss, optimizing revenue capture, and ensuring billing compliance. Minimizing revenue loss is accomplished primarily through management of pharmacy charge denials and can be an ideal first step in establishing a PRI program due to the tangible value generated. Optimizing revenue capture involves a combination of clinical expertise and understanding of billing operations to ensure medications are being billed and reimbursed appropriately. Finally, ensuring billing compliance, including ownership of the pharmacy charge description master and maintenance of electronic health record medication lists, is vital in preventing charge and reimbursement errors. Conclusion Successfully bringing traditional revenue cycle functions into the department of pharmacy can be a daunting task but provides significant opportunities to create value for a health system. Key factors to the success of a PRI program include robust data access, hiring individuals with financial and pharmacy expertise into PRI positions, strong relationships with the existing revenue cycle teams, and a progressive model that allows for incremental expansion of services.