Efficient and timely reimbursement is essential for the successful operation of your pharmacy. Proactive claims management facilitates quicker reimbursement and less rejected claims, which helps maintain the pharmacy’s cash flow and financial stability.
Pharmacies must minimise claim rejections and ensure they are paid accurately and promptly each month. Given the increased cost pressures on pharmacies and rising business costs, ensuring full reimbursement for medicines dispensed is an absolute must for all pharmacies.
Pharmacies manage hundreds of prescriptions daily, necessitating a quick, efficient workflow while maintaining a strong focus on patient health and wellbeing. Streamlining workflow in a pharmacy can be significantly enhanced by optimising processes. This approach frees up valuable time for pharmacists to focus more on patient care activities.
To ensure effective delegation, all dispensary staff should possess a comprehensive understanding of the claiming process. Relying on a single individual to manage claims each month exposes your business to significant risks when that person is absent for any reason, such as illness or holidays. Ensuring that all staff members are proficient in the claiming process not only safeguards against these vulnerabilities but also promotes consistency. By cultivating a team-wide competence in claims management, you can maintain operational continuity and uphold high standards of efficiency in your claim practices.
The Delegation Toolkit developed by #SMARTPharmacy is designed to assist in planning, delegation and organising daily, weekly, and monthly activities. By leveraging this toolkit, pharmacies can effectively manage resources, leading to improved efficiency and productivity in the community pharmacy setting. This toolkit, at ipu.ie > SMART Pharmacy > Resource Management, provides a structured approach to task delegation and resource management, making the operational aspects of running a pharmacy less challenging, and more efficient.
Often, the issues which result in claims being rejected arise during the dispensing process itself. Proactive measures in pharmacy operations can lead to significant benefits, including cost savings, reduced labour costs and enhanced patient care. Taking the initiative to guide your staff through the claim process step-by-step, will clarify the significance of same, transforming the claiming process into a smoother task for all involved. Improving the efficiency of the dispensing process will simplify the claiming process.
In order to ensure payment for items dispensed on Community Drug Schemes, pharmacies should keep the following in mind when dispensing/claiming.
Some prescribers, such as nurses or dentists, can prescribe within their scope of practice so the list of items allowed on the Community Drug Schemes will be reduced. A List of Dentists with GMS Contracts and Dental Prescribable Items, are also available on PCRS Online Services.
“Ensuring that all staff members are proficient in the claiming process not only safeguards against these vulnerabilities but also promotes consistency.”
Not all items are covered under all Community Drug Schemes, so ensuring that the supplied item is dispensed under the correct Community Drug Scheme is important. For example, some of the items for LTI are allowed under Core Medication Lists, and others can be approved as special patient arrangements.
When ordering items to be dispensed on Community Drug Schemes, ensure that all medicines have a GMS code (unless they can be claimed using 777- codes or on the Hardship or TB scheme). This means that inventory will be proactively managed and stock file will remain accurate.
Parallel imports often offer consumers access to branded products at lower prices, making them more affordable. Many of these products cannot be dispensed under the Community Drug Schemes because the manufacturer has not applied for a GMS code. It is also important for the actual PI (Parallel Imported) product dispensed to be recorded correctly in a patient’s medication record, as these products may look similar, and it is important that your team can identify a PI product and label it appropriately.
To purchase EMPs at Reimbursement prices use only suppliers indicated in HSE Circular 012/23. Report any products which can only be purchased at a price over reimbursement prices by emailing datainfo@ipu.ie, and the IPU Product File team will liaise with the company, the IPU Contract Unit, and the PCRS.
Addressing claim issues before they become problematic can prevent missed payment opportunities and avoid potential revenue losses. By identifying and resolving issues early, pharmacies can ensure a smoother claims process, leading to timely reimbursements and improved financial stability.
Verifying prescriptions is a critical task in pharmacy operations, pivotal for ensuring the accuracy and integrity of pharmacy claims. This process not only safeguards against potential errors but also ensures compliance with reimbursement requirements and boosts pharmacy claims management:
Claims should be submitted to the PCRS within the designated timeframes. To qualify for early payment, electronic claims must be received by the PCRS no later than midnight on the third working day of the month. Files submitted after midnight on the third working day, and before midnight on the seventh day of the month (not working day), qualify for normal payment. Where the seventh day falls on a weekend or a bank holiday, pharmacies must still ensure that their files are submitted either on or before the seventh day of the month, in order to be included in normal payment.
All Opioid Substitution Treatment Scheme claims need to be submitted manually and posted to the PCRS either on or before the tenth day of each month.
Also keep on top of your monthly claims for Hardship, Tuberculosis (TB) Medications and Medicinal Cannabis Access Programme (MCAP).
Early exception files will be available for download no later than four working days from receipt of the file and in most cases are available within 24 hours of transmitting your claim file. The final corrected exception file must be transmitted by midnight on the eighth working day. This timeline enables you to promptly identify and rectify any items or forms flagged by the PCRS as potential rejections. Unresolved exceptions will be transferred to the final exception file, accessible after your claim has been processed and paid and will also appear as rejections in the itemised claims listings for the respective claim month.
One hundred pharmacies will be randomly selected each month to submit their ‘yellow bag.’ If your pharmacy is selected, you will be contacted by Healthmail and notified that you must submit your paperwork at the end of the month, invoices excluded. The deadline for the receipt of supporting paperwork will be outlined in the email sent by the HSE-PCRS and usually is by 5.00pm on the fifth day of the month. If this deadline falls on a Saturday/Sunday/Public Holiday, supporting paperwork should be received by HSE-PCRS on the next working day.
To ensure smooth and accurate reimbursement processes, pharmacies should adopt several measures to manage their claims effectively. Firstly, it is essential to maintain a record of email confirmations for any exceptional circumstances, such as additional allowances or patient-specific requirements. These records serve as crucial documentation for payment reconciliation purposes.
Furthermore, pharmacies should analyse their monthly ‘Summary Listings’ to detect any discrepancies in payments received, versus expected. Monitoring the monthly ‘Summary Listings’ for unusual trends or potential errors is another recommended practice. This regular review helps in identifying and rectifying any issues promptly. Additionally, it is prudent to scrutinise and challenge any claims that have been partially reimbursed, ensuring that all eligible items are adequately compensated.
The Enhanced XML file provided by the PCRS clearly outlines payment discrepancies, and your system vendor can assist with the implementation of this valuable tool for claims reconciliation.
The IPU Contract Unit advises pharmacies to maintain a detailed log of all high-cost items dispensed each month. This log aids in reconciliation efforts and provides a clear audit trail for any discrepancies or queries that may arise.
Lastly, pharmacies should verify that the total fees paid for claims under the contraception scheme align accurately with the quantities of medications dispensed.
Rejected claims should be promptly addressed to minimise their impact on the pharmacy’s revenue stream. Conducting a thorough review and follow-up of rejections each month allows you to identify and rectify recurring errors. By carefully examining and correcting these issues, you can prevent them from reoccurring in subsequent claim periods, thus ensuring a smoother and more efficient reimbursement process.
The IPU Contracts Department is available to address any queries regarding pharmacy claims. You can contact us at 01 406 1557 or via email at contract@ipu.ie. The IPU Claims Guide, a valuable resource, can be accessed on our website.
The HSE PCRS maintains a repository of all circulars related to HSE PCRS community drug schemes at pcrs.ie. Additionally, the HSE PCRS provides the booklet HSE Primary Care Eligibility & Reimbursement Service (PCERS): Information and Administrative Arrangements for Pharmacists, which can be found on the Pharmacy Suite, or the PCRS website.
In the complex landscape of pharmacy management, adopting a proactive approach can be transformative. By reducing the disruptions and labour associated with reactive claim handling, pharmacies can focus more on their primary mission — providing exceptional healthcare services. This leads to a sustainable business model that benefits the pharmacy, its staff, and the community it serves.
Zrinka Bulj
Claims Analyst, IPU
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