Optimizing Pharmacy Workflow: How Pre and Post Edits (PPE) Help Make Your Pharmacy More Efficient

September 9, 2023

A Closer Look at: Optimizing Pharmacy Workflow

While Pre & Post Edits (PPE) have been available in various forms and levels of sophistication for decades, they are most often focused on prescription reimbursement and ensuring that the claim elements that affect payment are correct. These basic edits are the ones you are likely most familiar with such as AWP comparison, Quantity/Days’ Supply appropriateness, and DAW code usage.

Proper reimbursement is crucial for pharmacy profitability, but PPE solutions can be leveraged to help your pharmacy’s bottom line in other ways as well. One key area is operational efficiency, which means utilizing the edits to help improve pharmacy workflow and reduce costs. Not all PPE solutions are robust enough to be able to offer the flexibility and customization that is needed to meet each pharmacy’s unique workflow needs, which is what makes Veridikal’s DetectRx PPE solution so popular among pharmacies of all sizes who are looking to build on the basics of traditional PPE to fully optimize all aspects of their claims adjudication process.

How Does DetectRx PPE Improve Efficiency?

Fewer Rejections Mean Less Rework

Pharmacy claims contain dozens of data elements that each convey something about that claim to the payor. Ensuring that those data elements are populated correctly is challenging and often payor specific, so claim rejections are typically one of the main challenges that pharmacies contend with in terms of slowing down their workflow. Having to correct data elements and rebill claims takes time and requires well-trained employees, which adds additional staffing costs to your bottom line. DetectRx edits check claim elements before they go to the payor and is able to make corrections automatically or provide staff with specific guidance for making the needed adjustments proactively. These interventions result in a much higher percentage of ‘clean’ claims that are accepted and paid appropriately by the payor without any additional rework at the pharmacy.

Accurate Claims Result In Fewer Audits

Pharmacies work hard to serve their customers and maintain a profitable business, which is often made more difficult because of the poor reimbursement rates provided by many payors. The last thing that a pharmacy needs is for the payor to come back later and recoup some of those reimbursements via an audit. When adjudicating claims, it is not only important to populate the data elements to ensure that a given claim will be accepted for payment; it is equally important that the claim data be accurate and appropriate such that there are no red flags for potential future audit takebacks.

Proper usage of Dispense as Written (DAW), Submission Clarification Codes (SCC), and other identifiers meant to convey specific dispensing scenarios to the payor are often misused and are common audit triggers. There are many nuances to appropriate claim billing, and even for pharmacies who employ highly skilled billing staff the pitfalls are many. DetectRx is able to review every element of every claim in real-time to ensure that claim elements are populated appropriately, serving as a manager of sorts that provides oversite for the entire adjudication function. As regulations and audit trends change over time, DetectRx is able to adapt or create new edits to combat those changes and ensure that audit protections remain in place.

Customization Can Address Workflow Challenges and Identify Training Deficiencies

One of the more advanced features of DetectRx is that enables pharmacies to overcome Pharmacy Information System (PIS) setup limitations or inaccuracies. Essentially, any claim data elements that are adjudicated could potentially be managed with an edit. Our edits can be purpose built and custom messaging can be programmed to provide pharmacy staff with specific instructions for claim interventions or workflow routing. This functionality can also be used to help implement and manage pharmacy specific preferred drug or other formulary initiatives.

Because claim interventions are also tracked and reported upon, pharmacy leadership has oversight into staff behaviors related to edit overrides or responses to edit messaging. This allows managers to identify training opportunities where staff are not complying with the intended use of a given edit, which results in a better trained team, more efficient workflow, and less audit risk due to claim billing inaccuracies.

Pharmacy claims Adjudication with DetectRx

Learn How DetectRx Can Help Optimize Your Pharmacy Workflow

As pharmacy claim adjudication continues to grow more complex it becomes increasingly crucial to have tools that can adapt and evolve to the constantly changing requirements for accurate claim billing. Pharmacy Information Systems struggle to keep up with solutions to the myriad of challenges related to proper claim billing, which is the primary reason that DetectRx is so heavily relied upon by our client pharmacies.

Our Pre & Post Edit solution integrates seamlessly into your PIS and fills the gaps, identifies problems, and provides oversight and peace of mind.

Transforming the pharmacy industry through best-in-class solutions.

DetectRxHelps Maximize Reimbursement & Improve Productivity

Learn more about DetectRx, and Request a demo to learn how it can help you enhance productivity!