Examples of Revenue Recovered By Reimbursement Specialists

Management of Diabetic Supplies
In March 2001, a multidisciplinary Diabetic Supply Committee recommended to Senior Management that diabetic supply management be transferred to the pharmacy department in an effort to reduce wastes and improve disease outcomes. After developing a standardized order form for diabetic supplies and implementing dispensation procedures, the pharmacy initiated a Medicare application for DMERC supply billing. Following the receipt of a Medicare licensure for ambulatory pharmacy sites, approximately, $600,000 dollars of new revenue was generated by the pharmacy for reimbursement of diabetic supplies rendered to Medicare patients during August 2002 through May 2003. The program expanded to include billing for Immunosuppressive Drugs in January 2005.

Administration of Blood Factor Products to Inpatients
One hemophilia patient’s visit culminated in over $2.7 million charge for Novo Seven®. Because the patient was covered by Medicare, the pharmacy reimbursement specialist inquired about receiving separate payment for this drug from Medicare. It was found during this inquiry the hospital's financial services billing and coding staff were unaware that the hospital could charge Medicare for these products and get reimbursed separately.

Upon informing the appropriate parties that reimbursement was possible, an adjusted claim was submitted. The hospital received over $3 million in reimbursement for the aforementioned patient. Adjusted claims were then submitted for prior Medicare patients receiving any blood factor product. This resulted in the recovery of over $5 million in reimbursement.

Drugs dispensed to clinics not owned by the hospital
XYZ hospital has clinics some of which are owned by the hospital and others that are affiliated but not owned. The pharmacy reimbursement specialist realized that drugs were dispensed from the stock window in the main hospital and charged to patients visiting the non-owned clinics. When this practice was corrected by charging the clinics instead of the patients, the hospital no longer took a loss because they were no longer giving away these drugs. The lost revenue was estimated to be $50,000.

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