Understanding health care billing basics

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Abstract Objective To provide pharmacists a basic understanding of health care billing and current opportunities for generating revenue for their patient care services. Data Primary data source is CMS, as Medicare billing processes are viewed by the industry as the U.S. standard for health care billing. Summary The current U.S. health care billing process for patient care services is a complex and difficult system for many to fully grasp, especially pharmacists who are relatively new to generating revenue for patient care services. Health care billing is challenging for varied reasons, including multiple payers; nuances of the locations where services may be provided (i.e., institutional vs. noninstitutional); variation in state laws and regulations; and the legislative process, with regulations that change or are updated frequently, often yearly. Adding to the complexity is that health care billing has its own language of terms and abbreviations that, if not understood, impede billing discussions and interpretation of rules and regulations. Although health care billing models are moving away from fee-for-service to value-based payment models, it is important to understand the basics of the current model. The transition is not likely to completely overhaul the current system but over time to build on much of the current infrastructure as a starting point for the new billing models. This article provides the basics of health care billing and explains the particular details and processes pharmacists need to know to generate revenue for their services. Conclusion Although pharmacists have yet to universally establish themselves as health care providers able to bill payers in federal and state programs, they have the opportunity to work as auxiliary personnel under an eligible provider who may bill for a pharmacist's services. Thus, pharmacists are capable of generating revenue. The process remains complex and requires a clear understanding of the rules and regulations.