North Dakota Web-based Electronic Pharmacy Claim Submission Interface Abstract
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North Dakota Department of Human Services, Medical Services (ND Medicaid), proposes a web-based electronic claims submission interface for pharmacy claims.
Historically, pharmacies use the most advanced billing systems in the health care profession ? billing claims real-time and receiving responses in real-time for nearly two decades. However, small rural hospital based pharmacies in North Dakota have not been able to bill in this fashion. They are not outpatient pharmacies, yet if a person comes in when the community pharmacy is closed, they will dispense medication for home use if prescribed and bill the insurance (e.g. ND Medicaid). Since this is outside of the normal services provided by the hospital based pharmacy, and since outpatient pharmacy claims billing software is a large investment for such limited use, these pharmacies do not have a HIPAA compliant, NCPDP on-line billing system; they bill on paper claims.
Although some Medicaid agencies? computer systems provide a web-based claim submission system, we will not have that capability until 2009. Also, what we are proposing isn?t a claim submission system, but an interface that will provide the same feedback to the user as a pharmacy using a purchased pharmacy claims billing software package.
The goals of the program include:
- Provide a solution for pharmacies without an NCPDP claims billing system
- Eliminate the need for ND Medicaid to process paper pharmacy claims
- Decrease the error rate in pharmacy claims submission by this set of providers
- Identify abuse / mis-utilization at the point of service
Since this is essentially a design and build of a software application, most dollars will be spent on the front end, with only minimal maintenance and web-hosting costs after implementation. We estimate the total budget for this system at $75,000. This will include system analysis, licensing fees, system building, provider education, and information technology costs for linking the web-based system to our claims system.
By moving to 100% electronic claims for pharmacy, efficiency will be maximized. Staff time spent on paper claims entry and processing will be devoted to other areas of business. Also, the error rate for paper pharmacy claims is currently twice that of electronic claims; by eliminating paper filing and keying errors, this rate will drop. The effectiveness of our prospective drug use review edits will be maximized since paper claims, by definition, have not been subjected to prospective edits. We have also noticed a pattern of some Medicaid individuals using emergency rooms for diversion and abuse of narcotics. By having real-time claims processing for the hospital pharmacies, the effectiveness of our edits will be realized in 100% of ND Medicaid pharmacy providers.
The expected outcome of this program will be 100% electronic submission of pharmacy claims within three months of launch with saved staff time and a decrease in error rates for the affected providers.
