Understanding basic concepts and strategies for obtaining pharmaceutical reimbursement.
OBJECTIVE
The rules that govern pharmaceutical reimbursement and strategies for obtaining reimbursement for hospital inpatients and outpatients and patients treated at physician-owned clinics are discussed.


CONCLUSIONS
The use of certain claim forms and provision of information about the patient location, drug, Healthcare Common Procedure Coding System (HCPCS) code, status indicator, billing unit, revenue code, and International Classification of Diseases, 9th Revision (ICD-9) code are required to obtain reimbursement for pharmaceuticals from the Centers for Medicare & Medicaid Services. Requirements for hospital inpatients and outpatients differ. Claims for patients treated at physician-owned clinics are handled differently from claims for those treated at hospital outpatient clinics, but pharmaceutical reimbursement rates are the same in the two settings.


CONCLUSIONS
Frequent changes in the rules for obtaining pharmaceutical reimbursement present a challenge. A knowledge of the rules and requirements for different patient treatment settings is needed to obtain reimbursement.
Jarrett
Anne T
AT
Wake Forest University Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157, USA. ajarrett@wfubmc.edu
D000554:Ambulatory Care Facilities / Q000191:economics / Q000331:legislation & jurisprudence; D014487:Centers for Medicare and Medicaid Services, U.S. / Q000191:economics* / Q000331:legislation & jurisprudence; D011307:Drug Prescriptions / Q000191:economics*; D004469:Economics, Hospital / Q000331:legislation & jurisprudence; D049228:Healthcare Common Procedure Coding System; D006801:Humans; D007344:Insurance Claim Reporting; D007356:Insurance, Pharmaceutical Services / Q000191:economics* / Q000331:legislation & jurisprudence; D010044:Outpatient Clinics, Hospital / Q000191:economics / Q000331:legislation & jurisprudence; D012051:Reimbursement Mechanisms; D014481:United States