Provider Status
Ilisa Bernstein, PharmD, JD, FAPhA, and E. Michael Murphy, PharmD, MBA
“Provider status” is one of those terms that is easily recognized by members of the profession of pharmacy but sometimes has numerous meanings depending on its context. In this article, we explain what provider status is and why it’s important for pharmacists to get it.
What is provider status?
The term “provider status” ties back to the Social Security Act (SSA), which houses much of the federal law that created Medicare and Medicaid programs and includes a long list of providers and services for which Medicare and Medicaid will reimburse.
Although just about every other health care professional is represented on this list, pharmacists are excluded; therefore, pharmacists do not have provider status. Giving pharmacists provider status would add them to this list and allow for the reimbursement of their services by Medicare Part B (the medical benefit) as opposed to Medicare Part D (the prescription drug benefit).
Despite the history of the term, provider status has come to encompass a broad scope of recognition and expansion in pharmacists’ authority. However, a consistent theme in the term’s use is the ability for pharmacists to receive reimbursement for their services by health plans such as Medicare, Medicaid, and commercial insurance.
Why is provider status important for pharmacists?
Although the phrase “pharmacists getting paid for their patient care services” seems relatively straightforward, there is a surprising number of complexities and assumptions behind these 8 words.
In general, the goal is to align the reimbursement of pharmacists’ patient care services with how other health care professionals are reimbursed for comparable services.
This means reimbursement through the medical benefit using billing codes that are the same as other health care professionals’ and being reimbursed at a comparable rate. This is distinct from the reimbursement of medications under the pharmacy benefit, which includes ingredient costs and dispensing fees.
But why has this been one of—if not the top—priority of the profession for decades? It comes back to the fact that much of what pharmacists are currently providing or could provide to their patients is either being offered to the patient at out-of-pocket cost or for free.
The lack of insurance coverage for pharmacists’ services creates a financial disincentive for them to offer and provide these services. These disincentives create inefficiencies in the health care system that limit pharmacists in many care settings from providing care at the full height of their training and education. This results in one of the most extensively trained professionals being underutilized and undervalued in the health care system.
APhA, along with national and state partners, are working to make payment for pharmacists’ services possible through actions being taken at the federal and state level.
What is happening now?
Federal
For over a decade, there have been many iterations of federal legislation that would add pharmacists to the list of eligible providers for providing services to Medicare beneficiaries.
Because Medicare covers a significant portion of the population, Medicare’s coverage policies are often adopted by commercial plans and Medicaid. Medicare coverage could open many more doors regarding coverage, making federal provider status an essential trigger event.
The federal legislative attempts have ranged in scope from coverage of undefined pharmacist services, services associated with addressing opioid and substance use disorders, care for patients in areas of the country with health care professional shortages and medically underserved patients, and coverage of pandemic and future public health emergency related services.
Currently, there are two bills that are introduced and pending in the U.S. Congress. The first is the Pharmacy and Medically Underserved Areas Enhancement Act (H.R. 2759/S.1362), which was introduced in the U.S. House of Representatives (House) and U.S. Senate (Senate) in April 2021.
This law would add pharmacists as eligible providers of pharmacists’ services for Medicare Part B beneficiaries, specifically in medically underserved areas and those with health professional shortages. (These areas are specifically defined by the U.S. government.)
The other bill is H.R. 7213, the Equitable Community Access to Pharmacist Services Act (ECAPS), which was introduced in the House in March 2022. This bill recognizes the efforts of pharmacists during the pandemic. It establishes reimbursement pathways for certain pharmacists’ services for Medicare Part B beneficiaries. It also helps prepare for pharmacists’ services for future emergencies and public health needs as well as addresses gaps in health equity.
Specifically, the law would allow pharmacists to provide testing for COVID-19, flu, strep, and respiratory syncytial virus (RSV); treatment for COVID-19, flu, and strep; and immunization for COVID-19 and flu. It also would permit the secretary of the U.S. Department of Health and Human Services to authorize the reimbursement of pharmacists’ services to meet future public health emergencies and needs.
As of the writing of this article, ECAPS has not yet been introduced in the Senate, but the pharmacy community and supportive stakeholders are rallying around advancing this bill and taking advantage of the visibility and importance of these pharmacist services during the pandemic.
Both of these bills limit coverage to what is authorized under state scope of practice, which makes state efforts equally important and urgent.
State
There are primarily 3 pathways for pharmacists to get paid for their patient care services at the state level.
These include legislative or regulatory authorities that allow the reimbursement of pharmacist services by Medicaid, commercial plans, and contracting with a commercial health plan without legislative or regulatory authorities.
Legislative or regulatory authorities can either voluntarily permit or mandate the reimbursement of pharmacist services by either Medicaid or commercial plans.
When it comes to the scope of reimbursable services, states are taking different approaches. Many states allow pharmacists the ability to be reimbursed for a select set of services, such as tobacco cessation services, diabetes self-management training services, or medication therapy management services.
Other states are focusing on increasing access to public health–related services provided by pharmacists by allowing pharmacists to be reimbursed for these services. For example, some states allow pharmacists to provide hormonal contraceptive services or HIV pre-exposure prophylaxis/postexposure prophylaxis services and receive reimbursement for these services.
The goal for many states is to allow pharmacists to be reimbursed for a broad scope of their patient care services. Although there has been select progress in states for pharmacists to be reimbursed for all services under their scope of practice, many states only allow pharmacists to be reimbursed if the service is provided under a collaborative practice agreement or if a referral is placed prior to the rendering of the service.
Another approach that some individual pharmacists or groups have found success with is directly negotiating with health plans. Pharmacists have worked with health plans to create programs in which individual pharmacists are credentialed and receive reimbursement for specific services. Although the ability to directly negotiate with a health plan may appear to be the path of least resistance, there has been limited evidence to showcase widespread implementation of reimbursement of pharmacists’ services across a state without legislative and regulatory advancements.
The advancement of state efforts to reimburse pharmacists for their patient care services is connected to the federal strategy. As pharmacists’ scope of practice authorities increase in the states—thereby demonstrating the positive therapeutic and economic value associated with pharmacist care—this could be used to further support passage of a federal provider status bill.
Additionally, as reimbursement pathways open up and more pharmacists are able to provide services aligned with their education and training, it is expected that public perception of pharmacists will continue to evolve. Patients who recognize the benefits of pharmacist’s patient care services but are faced with barriers to receiving these services because their health plans limit or do not allow this coverage could be strong advocates for expanded authorities for pharmacists.
What can you do to get pharmacists paid for their patient care services?
There are many ways that pharmacists, students, and advocates for pharmacists can support the advancement of pharmacists’ provider status. Pharmacists can make a huge impact by contacting their state and federal elected leaders to educate them regarding the value of pharmacists’ patient care services and to ask them to support legislation that allows pharmacists to be reimbursed for their services.
APhA provides a variety of resources to support advocacy for these efforts at the federal and state level, including talking points documents, instructions for how to organize a meeting with an elected leader, and guides to support people who want to send a letter to an elected leader. These resources help advocates communicate their views through a variety of methods, including letters, virtual meetings, phone calls, or in-person meetings. Visit actioncenter.pharmacist.com to access these resources. Pharmacists can also recruit their patients to educate their elected leaders by providing personal stories and examples of how their pharmacist is their essential health care provider.
Provider status is needed to increase patients’ access to the services pharmacists provide, to help patients reach their therapeutic outcomes, to better align the role of the pharmacist with their training, and to improve the sustainability of the pharmacist’s business model.
Through legislative and regulatory advancements at the federal and state level, more pharmacists are receiving reimbursement for their services and more elected leaders are understanding the need to invest in the pharmacist. However, there is still much work that needs to be done and the profession needs all pharmacists, students, and advocates of pharmacists engaged in advancing this cause at both the state and federal level. ■