The field of specialty pharmacy medical billing is evolving fast, driven by increasing demand for expensive specialty medications, changing healthcare policies, and technological advancements. In the future, many key innovations and trends are expected to influence billing processes of specialty pharmacies. From the increasing use of biosimilars to the integration of medical and pharmacy claims, these shifts would enhance billing accuracy, streamline administrative workflows, and improve patient outcomes.
In this article, we will discuss the latest trends and innovations in specialty pharmacy billing services and how they are setting the stage for a more patient-centered and efficient healthcare approach.
#1 Specialty Pharmacy Billing Trend: Higher Use of Biosimilars
A new trend emerging in 2025 is the quick rise of biosimilars like Ustekinumab (Stelara). This is influencing both compensation rates and billing processes of specialty pharmacies. They are biologic medical products similar to but less expensive than the innovator or originator products. As they help with cost savings, their introduction is expected to improve reimbursement rates as payers are more likely to favor them over their branded alternatives. Therefore, adopting to this shift can benefit your pharmacy.
For that, you need to make the following adjustments to your specialty pharmacy billing practices:
- Adjusting to medical vs pharmacy benefits: Many biosimilars are traditionally billed under the medical benefit as they are administered in clinics. However, self-administered biosimilars, which are increasingly being introduced, need to be billed under the pharmacy benefit. So, specialty pharmacies must make suitable changes in their billing processes to accommodate different benefit structures.
- Learning latest billing and coding guidelines: Specialty pharmacies need to remain updated with the latest billing and coding regulations for every biosimilar to submit claims accurately and prevent denials.
- Handling more frequent pre-authorizations: As biosimilars are introduced, patients might have any resistance or preferences to using them. Therefore, there might be a need to handle appeals and prior authorizations more often.
- Contracting and negotiation: The competitive landscape created by biosimilars necessitates more strategic negotiation and contracting with payers. Specialty pharmacies need to navigate rebate agreements and formulary placements, which can influence billing and reimbursement.
#2 Specialty Pharmacy Billing Trend: Increased Transparency in Pricing
Pharmacy Benefit Managers (PBMs) are under high scrutiny to make rebate and pricing structures more transparent. This can enhance patient trust, help with the management of healthcare costs, and allow you to offer competitive prices while maintaining quality standards.
Transparent pricing can also help billing practices of specialty pharmacies in the following ways:
- Fewer billing errors: Clear pricing ensures that both patients and providers know the exact costs involved. This allows more accurate billing to avoid confusion for the payers. On the other hand, consistent pricing helps to standardize billing methods. Both these initiatives contribute to reducing billing errors.
- Streamlined claims processing: Transparent prices also help insurers process claims more effectively, verify claims promptly and reduce delays and rejections.
- Low risk of unexpected price hikes: In open pricing, pharmacies try to pass rebates directly to patients to minimize markups on specialty generics. This reduces the chances of unpredictable price rise which also creates convenience for billing.
#3 Specialty Pharmacy Billing Trend: Continued Growth of Value-Based Contracting
Specialty pharmacies have been shifting towards value-based contracting for a long time. It is an innovative payment system where reimbursement is based on the quality of the rendered services rather than the quantity. That is, coverage and payments are tied to a treatment’s performance rather than the volume of drugs dispensed. This trend aims to improve patient care while managing costs and is expected to grow further in 2025.
If you adopt this approach, here are a few changes that must be made to your specialty pharmacy billing:
- Share risk-sharing agreements with billers: Specialty pharmacies may create agreements with payers to share financial risk between them. If a medicine underperforms, the pharmacy may absorb some of the costs and incentivize them to improve the quality of care. Pharmacies should keep billers updated about these agreements so that they know how much amount they need to collect from payers.
- Adjust to complex billing processes: The switch to value-based contracts makes billing methods more complex. There is a need to manage and document different performance measures like cost savings, clinical outcomes and patient adherence for accurate billing.
- Meet enhanced data requirements: Specialty pharmacies need to track, analyze and report additional data such as patient health outcomes, any adverse events and treatment effectiveness to ensure they meet the approved performance metrics. This data can justify the provided value and ensure proper reimbursement.
#4 Specialty Pharmacy Billing Trend: Integration of Pharmacy and Medical Claims
Integration of medical and pharmacy claims is another trend in specialty pharmacy medical billing. It not only boosts operational efficiency but also improves patient care by supporting a more patient-centric, coordinated and efficient approach to healthcare.
This trend allows specialty drug costs to be managed better and enhances billing accuracy in the following ways:
- Comprehensive patient data: Pharmacies would get a complete view of a patient’s treatment history including diagnoses, procedures and medications. This helps ensure accurate billing and shows the entire scope of rendered care.
- Fewer errors: This transition helps find and address discrepancies between medical and pharmacy claims. For instance, if a drug is billed but not documented in the medical record, this inconsistency would be flagged by the integration, which would reduce billing errors.
- Enhanced coordination: Healthcare providers can better coordinate care using integrated data to ensure that treatments are properly billed. This helps prevent duplicate billing and makes sure that all services are documented.
- Better reimbursement: Comprehensive and accurate billing data can help get precise reimbursement from payers. By showing the whole range of care provided, specialty pharmacies can justify their claims and lower the chances of rejected or delayed payments.
Outsource Specialty Pharmacy Billing Services to a Trusted RCM Company
Besides the above trends, categories of payers of specialty pharmacies are expected to expand and include integrated delivery networks and health systems besides insurance providers. This too will impact billing processes. Aligning with all these trends can add to operational complexity. Therefore, it is a good idea to outsource specialty pharmacy medical billing services to a reliable billing company like RCM Workshop. Our revenue cycle experts, experienced in handling cashflow of specialty pharmacies, can take care of your operational workflow and accommodate these trends efficiently into your billing methods. Take this step without further ado to improve your pharmacy’s financial health as well as patient care and satisfaction.