New Solutions to Pharmacy Reimbursement Concerns

AUGUST 26, 2019
Aislinn Antrim, Assistant Editor


John King, CEO, and David Pope, Chief Innovation Officer, of OmniSYS, discuss how they're tackling reimbursement issues for pharmacies. This video was filmed at the 2019 NACDS Total Store Expo.

John King: Reimbursement is a critical issue and it can be complex, particularly around medical benefits, as not many pharmacies are familiar with that aspect. OmniSYS has been in the business of medical claims processing for 25 years; we are the industry leader in that area. And from a workflow perspective, the way our product works is very similar to how a pharmacy would adjudicate to a PBM. Simply, a pharmacist would enter a claim for one of the goods or services covered under a medical benefit—things like diabetic supplies, DME items, immunizations—and also a growing list of new clinical services like birth control prescribing, biometric screening, or point-of-care diagnostic testing. But when they adjudicate that claim against CareCLAIM, they bounce against our front-end transactional editing system, where we have real-time eligibility to payers. We also have hundreds of proprietary edits, which ensure that there’s pricing accuracy and that those claims are payer-compliant. And then on the back end, we provide an integrated set of revenue cycle services such as denials management and auditing.

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