6 Reimbursement Hurdles for Your Infusion Pharmacy to Overcome

Learn tips for taking on infusion back-office challenges

Infusion pharmacies often encounter numerous roadblocks when it comes to managing their reimbursement processes. From hiring the right personnel to implementing effective workflow strategies, running a smooth back office can be a daunting task. To help infusion pharmacy providers overcome their back-office obstacles, Prochant’s Pharmacy Reimbursement Manager, Tina Ratliff, hosted an insightful webinar about managing your back-office operations and maximizing staff potential. 

1) Staffing for Success 

The first thing Tina emphasized was finding the right people for your team. It’s no secret that staffing for success is a challenge. You need someone who is not only qualified for the role, but they also need to fit in well with your established workplace environment.

“Making sure you have the right people in the right spots is just as important as just having people,” Tina said during the webinar. When recruiting for a position, your priorities should be a potential employee’s industry experience, adaptability, and strong communication skills.

While there are many things that can be taught on the job, a person’s attitude and work ethic are traits they bring with them. If a candidate applying doesn’t have the most work experience, but they do have the motivation and drive to learn, and adapt to your team’s culture, it’s worth investing in a candidate who shows potential than hiring someone who lacks the necessary drive and adaptability.

2) Developing a Winning Strategy 

Another hurdle infusion pharmacy providers come across is implementing realistic goals and a new workflow strategy.

“When you are coming up with your strategy, what specifically do you want to turn around? Is it measurable?” Tina asked providers. 

If the goal you present to your staff seems unattainable from the start, they might give up before they get started. First and foremost, have SMART goals: Specific, Measurable, Achievable, Relevant, and Time-bound. 

While setting your new goals, it’s essential to consider your key performance indicators (KPIs). Examining your data and tracking can help you identify any problems that require immediate attention.

Once your goals are defined, you need to create your workflow strategy. When doing this, it’s crucial to involve all team members in the decision-making process, since your new strategy only works if everyone on board understands. Everyone has a different learning style and may need help with new workflow optimization changes you implement. Monitor their progress as everyone gets comfortable with the new strategy. 

3) Intake Insights 

If you have an accounts receivable (A/R) problem, it’s essential to identify the broken link in your chain. Starting with intake, create a standardized practice. Tina recommends creating a template that staff can use to record intake consistently. This is particularly helpful for patient registration.

In addition, it’s crucial to pay special attention to insurance verification, as this is often the determining factor in whether you get paid or not. Tina recommends verifying insurance for every new patient or new therapy and making sure codes are covered and the patient has infusion benefits. Make sure you outline as much as you can on your insurance verification forms for your records. 

Communication is also key in the workplace. Especially with prior authorization and prescription processing, clear communication is needed between your different departments and when speaking to your insurance representative. Whatever system you use, make sure everything is coded correctly and that the right departments know about any changes. For instance, the billing department needs to know if any codes have changed before submitting a claim. 

4) Billing Breakthroughs 

Coding accuracy in billing is another hurdle infusion providers have to deal with. Since codes change periodically, it’s crucial to stay on top of these developments. Luckily, there are a lot of resources available to do so. Sometimes companies will host webinars (like Prochant) or post newsletters that help providers with ongoing education. By taking advantage of these resources, you can ensure your team has the knowledge and skills needed to handle coding accurately. 

Another billing hurdle revolves around payment tracking. Tip: Do things electronically as much as possible, create proof of filing, and get documentation loaded through patient portals. This all helps prevent claim denials. Most importantly, post your denials. This is vital when looking at your metrics. Posting denials will allow you to find trends in your KPIs before there is a huge hit to your A/R rate. 

5) Payer Level Perspectives 

Just like with coding changes, it is also vital to stay informed about changes at the payer level. If it helps, designate a point person to keep up to date with infusion webinars and have them sign up for alerts from NHIA, Medicare, and other organizations.

Having an open line of communication with your payers will also help you in the future when issues arise. If a payer has stopped paying for a certain drug, having a point person who can communicate effectively with the payer can help you quickly resolve the issue and avoid delays for your back-office team and collectors. 

6) Denial Detection 

Denials can provide valuable insights into your team’s performance and be an indicator of potential issues. “Strike while the iron’s hot,” Tina said. 

The moment your claim gets denied, have someone work on it to get your infusion pharmacy paid. Working on your denials in a timely manner and having weekly denial reviews by type, payer, and reason will allow you to drill down into any issues.

Tip: Identify trends in your denials. If you notice an uptick in denials with a certain payer, that is a red flag that could indicate an issue needs to be addressed. Sometimes a payer switches systems and has to reload your contract, but they don’t do it correctly.

Continue to monitor your denials. If you are routinely getting the same denials, it means you could be doing something wrong, or a payer could be doing something wrong and maybe not realize it. Keep monitoring trends to act on small problems before they become major obstacles to getting paid.

Next Steps 

With any questions about this webinar recap or the full presentation below, please email Prochant expert Tina Ratliff at tinar@prochant.com or contact Prochant here.

To help your team with workflow implementation and KPI drill down capabilities, learn about Prochant Analytics, our secure solution here. 


Prochant has a proven track record of helping HME and pharmacy providers meet their financial goals. Our scalable solutions, years of experience, and advanced technology provide best-in-class results to the healthcare community. Headquartered in Charlotte, North Carolina, our client base includes national pharmacy and HME providers and health systems.