Dedicated billing teams running Part D claim submission, PBM coordination, MFP drug reconciliation workflow under the 2026 negotiated price rules, third-party claim resolution, DIR fee tracking, and audit-ready documentation. PharmDs oversee clinical edits. Among the few enterprise pharmacy billing partners with HIPAA Certified, SOC 2 Type II, HITRUST-aligned, and ISO 27001-aligned controls. Live in 2 weeks.
One outsourcing partner for every enterprise workflow.
AI runs the first pass, a trained specialist owns the outcome, inside your existing systems.
LTC pharmacy billing is the dispensing pharmacy’s workflow for submitting Medicare Part D claims, coordinating with PBMs on contract pricing and rebates, reconciling third-party claims across ALF and LTC payers, tracking DIR fees, and maintaining audit-ready documentation. The buyer is the Director of Pharmacy or pharmacy owner. The workflow lives in FrameworkLTC, PioneerRx, or PrimeRx and feeds into PBM portals on the back end.
Part D plans reimburse a fraction of true dispensing cost on brand medications for LTC pharmacies. Reconciliation, DIR tracking, and audit-ready posture move the conversation from cash flow chaos to predictable monthly close. Staffingly runs that workflow inside your PMS.
LTC pharmacy billing handles cycle fill, facility-coded claims, MAR-driven dispenses, and ALF private-pay coordination on top of standard Part D submission. Cycle fill billing requires a different claim cadence than 30-day retail fills.
ALF claims often blend Medicaid waiver, private pay, and Medicare Part D. The reconciliation work is larger and the audit risk profile is different.
Starting January 1, 2026, for drugs covered under the Maximum Fair Price program, PBMs reimburse pharmacies at or below the lower negotiated price up front. Drug manufacturers then have 14 days to refund pharmacies separately.
We track the dual payment stream against the original claim and produce reconciliation reports showing both the PBM payment and the manufacturer refund.
Pharmacy-side prior authorization is a separate Staffingly department. The billing team coordinates with the PA team when claims reject for missing PA.
For dispenser-side PA workflows including Part D coverage determinations and formulary exceptions, see our Prior Authorization for LTC and ALF Pharmacies spoke.
Real quotes from active pharmacy clients. Names and affiliations anonymized for client confidentiality. Reference calls available under NDA.
“Just wanted to give a shoutout to the Audit Team from Staffingly. ALF audits have become a really big focus project lately for two major groups.
The size of the project would have taken me weeks to complete even with another person helping. Now the audits are being cleared in a maximum of 3 days per facility, often even faster than that.”
Matt, Pharmacy Client Manager . Multi-state LTC Pharmacy Chain
“Very amazing job by Staffingly. We acquired a pharmacy where a data migration was not available. Staffingly helped us input all data accurately and efficiently.
We had 30 days to finish the job and they did it in 21. Very impressed by their work ethic, professionalism, and accuracy.”
Kushal S., Owner . Acquired LTC Retail Pharmacy
“Third-party rejection backlog cleared inside 30 days. DIR fee reconciliation went from a quarterly fire drill to a monthly cadence. Audit packages are ready when the PBM requests them, not scrambled together after the fact.”
Ezriel B., Outsourcing Manager . Multi-state LTC Pharmacy Chain
“Staffingly’s attention to detail is outstanding. The team handles inquiries from long-term care facilities, including doctors, nurses, and directors of nursing, with such efficiency that everything runs smoothly.”
Abraham G., Pharmacy Operations Lead . LTC Pharmacy Network
“I just want to take the opportunity to recognize and thank Staffingly. They have truly been an asset to the company. They have consistently demonstrated care and passion when serving our customers.”
Ferdy A., Pharmacy Operations . LTC Pharmacy Network
All quotes verified against internal records. Reference calls available under NDA. Client names anonymized for confidentiality.
PBM reform, MFP rollout, and Part D reimbursement pressure all hit the same year. We absorb all three.
The Consolidated Appropriations Act, 2026 was signed February 3, 2026 and includes PBM reform language with enhanced right of audit for PDP sponsors. Pharmacy billing departments need audit-ready posture by default.
Source: Consolidated Appropriations Act, 2026 (signed Feb 3, 2026)For MFP drugs since January 1, 2026, PBMs reimburse at or below the lower negotiated price up front, and drug companies have 14 days to refund pharmacies separately. The dual payment stream needs parallel reconciliation.
Source: CMS Maximum Fair Price program, Jan 1, 2026Part D plans reimburse a fraction of true dispensing costs for LTC pharmacies, especially on brand medications. Tight reconciliation of every claim is the difference between margin and loss on the cycle fill.
Source: SCPC pharmacy reimbursement analysisReconciliation lag, DIR exposure, and PBM audit visibility. We move all three within 90 days.
Same Staffingly roster, same four-certification posture, same audit-ready posture across all eight.
NCPDP-formatted Part D claim submission through the pharmacy management system. Real-time adjudication monitoring, rejection routing, and resubmission workflow.
Contract pricing verification against PBM rate sheets. Rebate reconciliation. Network status tracking. Communication on contract amendments.
Parallel tracking of PBM payment and 14-day manufacturer refund for MFP drugs under the 2026 negotiated price program. Dual-stream reconciliation reports.
Rejection root-cause analysis, COB resolution, secondary payer coordination, and resubmission with corrected data. Tracks aging buckets for cash flow visibility.
ALF private-pay coordination, Medicaid waiver claims, and facility statement reconciliation. Tagged by facility for clean monthly reporting.
7-day, 14-day, and 30-day cycle fill claim cadence. MAR-driven dispense reconciliation. Short-cycle compliance with CMS LTC pharmacy rules.
Monthly DIR fee assessment reconciliation against the original claim. Trend reporting by drug class and PBM. Net effective reimbursement visibility.
Monthly close packages aligned to PBM audit standards and Consolidated Appropriations Act, 2026 right-of-audit posture. Ready to ship on request.
A dedicated billing team is assigned to your pharmacy. They log into FrameworkLTC, PioneerRx, or PrimeRx over secure remote desktop, submit Part D claims through NCPDP, run PBM third-party reconciliation, track DIR fee assessments, file MFP drug reimbursement workflows under the 2026 negotiated price rules, and produce audit-ready monthly reconciliation packages. PharmDs and US-licensed pharmacists oversee clinical edits. We staff three shifts daily to cover all US time zones. 2-Week Risk-Free Pilot, BAA Signed.
Day 1 to 2. Scope claim volume, payer mix, PBM contracts, cycle fill cadence, and pilot success criteria.
Day 3 to 5. BAA signed. PMS and PBM portal access provisioned under zero-trust with MFA and audit logging.
Day 6 to 10. 2 to 3 hour SOP training. Billing team assigned. Shadow runs on Part D submission and reconciliation with daily QA.
Day 11 to 14. Claims flow live. Weekly reconciliation cadence established. Decide at day 14 whether to scale to 24/7.
Pilot live in 2 weeks with BAA signed. 2 to 3 day onboarding and 2 to 3 hour SOP training. Full 24/7 billing coverage across three shifts in 4 to 6 weeks depending on claim volume and SOP complexity.
AI handles claim scrubbing, rejection pattern detection, DIR fee assessment matching, and PBM contract pricing checks. PharmDs and US-licensed pharmacists own clinical edits, controlled substance billing decisions, and audit defense strategy.
Pre-submission claim scrub against NCPDP rules, PBM-specific edits, and DUR alerts. Flags claims likely to reject before they hit the adjudicator.
Trained on Google Gemma deployed locally for HIPAA compliance, designed to minimize external PHI transmission through locally hosted workflows.
Matches monthly DIR fee assessments back to the original claim. Surfaces over-assessments and missing offsets. Builds the appeal package automatically when a fee disputes against contract terms.
Tracks the dual payment stream for MFP drugs. PBM payment at or below the negotiated price plus the 14-day manufacturer refund. Flags missed refunds. Closes the loop on every MFP dispense.
PharmDs and US-licensed pharmacists stay in the loop on every clinical edit. AI accelerates the deterministic 80 percent.
Against in-house, Staffingly is roughly 67 percent cheaper at the same coverage. Against a single-source pharmacy staffing platform, Staffingly is faster to live, certified deeper, and free of per-claim markup or multi-year lock-in terms.
| In-House Billing | Single-Source Pharmacy Staffing Platform | Staffingly | |
|---|---|---|---|
| Pricing model | Billing FTE W-2 cost plus benefits plus tax | Per-claim or per-fill markup, hourly contractor rates | $299 to $399 weekly per resource. Predictable monthly opex. |
| Contract terms | Open-ended W-2 headcount | Annual minimums, per-fill markup | Month-to-month, no lock-in |
| Onboarding speed | 6 to 12 weeks to hire and train a billing FTE | 2 to 4 weeks per placement | 2-Week Risk-Free Pilot. 2 to 3 day onboarding. 2 to 3 hour SOP training. |
| PharmD oversight | Pharmacist in Charge time off the bench | Limited or none | PharmDs and US-licensed pharmacists in the loop on clinical edits |
| MFP workflow | Manual reconciliation | Often not handled | Dual-stream PBM payment + 14-day manufacturer refund tracking |
| DIR fee tracking | Quarterly fire drill | Limited | Monthly reconciliation cadence with audit-ready packages |
| 24/7 coverage | Requires 3 in-house shifts | Limited overnight and weekend coverage | All 3 shifts, all US time zones, multi-state |
| Certifications | Internal HIPAA training | HIPAA plus sometimes SOC 2 | HIPAA Certified, SOC 2 Type II, HITRUST, ISO 27001 |
| AI layer | None | Vendor-locked SaaS | Staffingly.AI (ML claim scrubbing, DIR match engine, MFP tracker) |
| PBM Reconciliation Risk Alignment | Full internal absorption of staffing overhead and PBM contract complexity. | Vendor concentration limits. Contingent pricing penalizes claim volume increases. | Predictable opex. Vendor-absorbed turnover protection with redundant team coverage and disaster-recovery demonstrated in live operations. |
Our four-certification stack is independently verifiable. We provide certificates on request under NDA.
A typical in-house pharmacy billing FTE runs around $5,000 per month fully loaded. Staffingly runs around $1,650 per month per dedicated billing resource. Roughly 67 percent reduction with the same throughput and audit-ready posture.
The 67 percent figure is based on BLS pharmacy billing compensation plus typical fully-loaded employer cost compared to the $1,650/mo Staffingly rate. Savings vary by region, claim volume, payer mix, and pilot scope.
Estimated savings based on U.S. Bureau of Labor Statistics Occupational Employment and Wage Statistics for Pharmacists (SOC 29-1051) and typical employer overhead. Actual savings vary by staffing model, geography, and shift differentials.
Three anonymized engagements. Reference calls available under NDA.
ALF audits across two facility groups completed in a maximum of 3 days per facility. Audit-ready posture means PBM and facility audit requests are answered the same week, not after a month of scramble.
80 to 90 LTC facilities across the Midwest. Billing department coverage maintained 24/7 with redundant team coverage during in-house staffing shortages. DIR cadence moved from quarterly to monthly.
Stood up MFP dual-stream reconciliation workflow January 1, 2026. Every MFP dispense tracked against the PBM payment and the 14-day manufacturer refund. No documented missed refunds during monitored Q1 operations.
All outcomes verified against internal records. Reference calls available under NDA on request.
Independent third-party HIPAA certification and current SOC 2, HITRUST, and ISO 27001 attestations are in place across the pharmacy billing operating footprint.
Current certificates available under NDA on request.
Pick Part D submission, PBM reconciliation, or MFP workflow. No setup fee, no per-claim markup, no multi-year lock-in. BAA signed before any PHI moves.
Eight buyer-side questions we get on every pharmacy billing call. Direct, conversational, web-verified answers.
Pick Part D submission, PBM reconciliation, MFP workflow, DIR tracking, or ALF claim handling. See reconciliation lag, DIR exposure, and audit-readiness scoring in under 14 days. Month-to-month after the pilot. No per-claim markup. No long-term lock-ins.
HIPAA Certified . SOC 2 Type II . HITRUST . ISO 27001 . 800+ providers served.
Dan Nandan is the President and CEO of Staffingly, Inc. With 25+ years across IT consulting, healthcare BPO operations, and AI automation, he was one of the earliest US operators to set up an RPO/BPO delivery network in India over 20 years ago. Today his work centers on production AI deployments inside LTC pharmacy chains, specialty pharmacy networks, assisted living facilities, and retail pharmacy operations across North America.
Shammi Chapalamadugu, RPh is the Director of Pharmacy Operations at Staffingly, Inc. and a licensed pharmacist in the State of Florida (License No. PS39122). He reviews pharmacy billing content at Staffingly for clinical accuracy, Part D reconciliation fit, and compliance terminology. Day-to-day work covers Part D submission, PBM coordination, MFP drug reconciliation, DIR fee tracking, and audit-ready documentation across long-term care, assisted living, and specialty pharmacy operations.
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