Patient Leakage from E-Prescribing Outside Network Pharmacies
Definition
Physicians using e-prescribing (EPCS) send prescriptions to external pharmacies, causing patients to fill outside the health system's network and breaking care continuum. This leads to lost revenue from pharmacy services and reduced visibility into patient treatment adherence. Health systems face this recurring issue amid declining volumes and negative margins.
Key Findings
- Financial Impact: Billions industry-wide annually from leakage (no per-practice figure, but essential revenue center loss)
- Frequency: Daily
- Root Cause: E-prescribing defaults to out-of-network pharmacies without system-owned options, lacking integration for in-network capture
Why This Matters
This pain point represents a significant opportunity for B2B solutions targeting Physicians.
Affected Stakeholders
Physicians, Health System Pharmacists, Practice Managers
Deep Analysis (Premium)
Financial Impact
$1,500-$3,500 per 1,000 Tricare patients annually in compliance gaps + potential Tricare audit findings/corrective action plans • $1,500-$4,000 per 1,000 Tricare patients annually in lost margin + potential Tricare compliance audit findings • $1,500-$5,000 per 1,000 Medicare patients annually in lost pharmacy margin (2-4% leakage) + compliance reporting gaps
Current Workarounds
Manual cash price quote spreadsheets; phone-based price matching; patient outreach via text/email; manual discount card enrollment • Manual chart review of pharmacy claims lag (30-60 days); phone outreach to reconcile fills; Excel tracking of medication adherence gaps; monthly reporting rework • Manual claims lag reconciliation (30-60 days); phone outreach to patients; Excel adherence tracking with known gaps; monthly corrective action meetings
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Methodology & Sources
Data collected via OSINT from regulatory filings, industry audits, and verified case studies.
Related Business Risks
Missed Charges and Coding Errors in E-Prescribing to Billing Workflow
Bottlenecks in Documentation-Coding Handoff
Under-coding and Missed Charge Capture in E/M Coding
Denied Claims from Improper Documentation and Medical Necessity Issues
Extended A/R from Documentation-Related Soft Denials
Fines from Documentation Breaches Tied to Coding Compliance
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