Navigating the RCM Challenges of Specialty Pharmacy

Insights from the Annual National Association of Specialty Pharmacy (NASP) 2023 Conference

The recent National Association of Specialty Pharmacy (NASP) conference highlighted critical developments, challenges, and opportunities in the world of specialty pharmacy. This article aims to share key insights from the conference, offering a pragmatic look at the evolving specialty pharmacy environment and providing actionable strategies to tackle emerging challenges effectively. Whether it’s managing reimbursement hurdles, optimizing admission accuracy, or enhancing prior authorization processes, these insights are integral for those looking to understand and adapt to the dynamic nature of specialty pharmacy today.

Evolving Healthcare Landscape

The specialty pharmacy sector is in a state of continual evolution, adjusting to meet the diverse needs of different populations. Notably, with approximately 12,000 Baby Boomers reaching the age of 65 daily, and projections estimating around 4.4 million reaching this milestone in 2024, the demand for specialized healthcare services is reaching unprecedented levels. The complexities brought about by an aging demographic, longer life expectancies, and intricate specialty care needs have made specialty pharmaceutical solutions more critical than ever, addressing conditions like arthritis and joint treatment among others.

To navigate the multifaceted healthcare landscape effectively, embracing advanced technologies and innovative business models is crucial. Specialty pharmacies need to consider forming alliances with third-party entities for managing Revenue Cycle Management (RCM). Such strategic partnerships allow specialty pharmacies to concentrate their resources and expertise more on patient care and regulatory compliance.

To remain competitive and thrive in this scenario, adopting AI technologies and tailored business models is paramount. Specialty pharmacies should also contemplate leveraging third-party partnerships for revenue cycle management, allowing them to channel their focus more towards patient care and compliance.

Refined Admission Entry Process in Specialty Pharmacies

Specialty pharmacies face the intricate challenge of managing high-volume prescription processing, necessitating the implementation of meticulous, accurate, and timely orders. Each prescription must strictly adhere to regulatory and procedural guidelines to ensure proper billing and tracking, mitigating any potential discrepancies. The introduction of efficient systems to access and enter new patient documents and incoming orders is vital. This approach allows for the real-time evaluation and prioritization of orders, considering patient needs and pharmacy delivery schedules, and it supports a 24/7 workflow, enabling the processing of prescriptions even during after-hours, ensuring continuity of care and service delivery.

Prioritizing Efficiency in Prior Authorizations

The prevalent manual handling of prior authorizations within the healthcare sector often leads to inefficiencies, with substantial time spent on hold or sending faxes for approvals. Streamlining this process is crucial, allowing pharmacy staff to allocate their time more efficiently to tasks specifically pertaining to pharmacy operations. The implementation of a system that can process and submit approval requests electronically, around the clock, ensures swift turnarounds. This expedited and streamlined approach to securing approvals ensures prescriptions are processed efficiently, and patient needs are aptly met, enhancing overall patient satisfaction and healthcare delivery.

Addressing Increasing Billing Volumes Effectively

Managing the intricate aspects of billing, ranging from account set-up to insurance verification, is crucial in the face of growing business demands. Enhancing efficiency in managing the voluminous daily workflows is pivotal to improving reimbursement processes and adapting to the elevated operational demands. The deployment of efficient management strategies is vital, allowing the staff to absorb the increasing pressures of expanded business and to focus on pivotal aspects of pharmacy management and patient care. Efficient handling of billing volumes ensures the seamless operation of pharmacy services and contributes to optimized patient outcomes and organizational productivity.

The Pharmacy Revenue Cycle

You face many daily obstacles when operating a specialty pharmacy. Revenue cycle challenges, including payment for your services, are likely at the top of that list.

Let’s review the pharmacy revenue cycle so that we can better understand it.


The pharmacy revenue cycle contains many moving pieces and parts. From the time specialty pharmacies receive a referral, the clock is ticking to move patients smoothly through each process. However, you may face delays such as:

  • Old A/R getting older,
  • Challenging accounts or payers,
  • Lacking experienced insurance collectors,
  • Auditing concerns from Medicare or other payers, or
  • Needing another set of eyes to look at billing.

As your staff falls behind, you might also notice errors in your billing.

The Path Forward

Evaluating and implementing strategies, including adopting third-party partnerships, can lead to considerable efficiencies and cost savings, positioning your pharmacy to meet the escalating demands proficiently.

The integration of advanced technologies and refined business models not only aligns with the need for organizational benefit but also emphasizes a patient-centric approach, fulfilling the core objective of healthcare—providing optimal care to those in need.

With the continuous expansion and critical role of specialty pharmacies, leveraging insights from platforms such as the NASP conference is invaluable in reshaping strategies to address the evolving needs and challenges in specialty pharmacy effectively.

Connect with us today to learn more about how our reimbursement experts can help optimize your revenue cycle management!

Prochant is the only AI-driven reimbursement service provider in the home-based care industry. We deliver focused revenue cycle management (RCM) solutions to healthcare providers with 7 wholly-owned global delivery centers. Our expertise lies in providing end-to-end RCM for home-based care, infusion, and specialty pharmacies, consistently delivering exceptional results to some of the leading healthcare providers in the country. We harness specialized automation technology and deep industry knowledge to streamline the time-consuming and expensive reimbursement process. As a result, we help healthcare providers accelerate their collections, increase revenue, and reduce operational costs while managing risk. Prochant is HITRUST certified, the gold standard for HIPAA security.