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What is Pharmacy Reconciliation?


Author: Payton Ebberts, Associate Account Analyst, Net-Rx™


Pharmacy claims reconciliation is the process of matching the point-of-sale adjudication, also known as the promise-to-pay amount, from the third-party payer to the amount actually paid. It is best practice to reconcile at the claim level to ensure you are reimbursed correctly for each claim.  You can automate and streamline the reconciliation process using pharmacy reconciliation software, which may help highlight missed revenue opportunities. For pharmacies unfamiliar with or needing assistance on reconciling claims, teaming up with the right reconciliation solution can simplify the process.


Streamline Through Automation – Electronic Remittance Advices
Pharmacy claims reconciliation can be tedious and laborious when dealing with paper remittance advices, also known as "Explanation of Benefits." Remittance advices outline how much a plan paid the pharmacy on a claim and any adjustments that were made. While it is possible to manually match payments received from the third-party payer to the point-of-sale adjudication, it is not feasible due to the high number of paper remittance advices. Even a small pharmacy could have hundreds of claims to reconcile each week. This process can be further complicated when taking claim reversals and fees into account. However, electronic remittance advices, also known as 835 files, can be generated by most third-party payers. The electronic remittance advices allow for automated reconciliation, reducing pharmacy labor, and improving efficiency.  


A vendor-neutral reconciliation solution like Net-Rx™ works with all major software vendors and can reconcile all third-party claims, regardless of the pharmacy’s participation with a Central Pay. Net-Rx™ can help pharmacies obtain the electronic remittance advices for automated reconciling and provide them with 24/7 access to a secure web portal for real-time reconciliation.


Tracking Outstanding Payments – Money on the Table  
According to an IQVIA Nation Prescription Audit1, pharmacies billed third-party payers for 95% of retail prescriptions filled in the U.S. in 2019. It can take days, or even months, for the pharmacy to receive payment for these claims.  This means that a considerable portion of a pharmacy's claims revenue may be outstanding for an extended, sometimes unknown amount of time. Pharmacies should keep track of which third-party payers impact their outstanding revenue most and when they expect to receive payment2 since unpaid or underpaid claims need to be addressed before they can no longer be recovered. 


Net-Rx's analysts provide pharmacies with industry knowledge and detailed reporting, which makes tracking and acting on outstanding payments more manageable.


To learn more about Net-Rx's reconciliation solution, visit: https://www.net-rx.com/Products/RecRx/, or contact us at Sales@Net-Rx.com / 1-866-336-3879.


1. https://www.kff.org/health-costs/state-indicator/total-retail-rx-drugs/?dataView=1&currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
2. https://www.liveoakbank.com/pharmacy-resources/lifecycle-of-a-prescription/



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This post is related to:

Claims Processing & Reconciliation