Reimbursement
Loren Bonner
Up in the mountains of Colorado, Lucas Smith, PharmD, wears many hats as the owner and lead pharmacist of two independent community pharmacies.
“With Colorado’s broader laws allowing pharmacists to treat many conditions, I am looking for other services we can offer to help our community and relieve the stress on the one walk-in clinic we have in the county,” said Smith, who owns and operates Buena Vista Drug and Salida Pharmacy & Fountain.
On the days he’s staffing the pharmacy, he checks prescriptions and counsels patients on their medications. But with the use of the pharmacy’s clinical documentation and billing platform, his team is able to integrate clinical services into their workflow without the need for additional pharmacy staff.
“My pharmacy technicians are all trained to help collect initial intake information from a patient and perform the POCT test, which allows the pharmacist time to continue checking prescriptions and step into the clinical service appointment when their education and knowledge is needed to help the patient,” he said.
Colorado’s law allows broad reimbursement under Medicaid for pharmacists with a CPA in place and includes statewide protocols that allow independent prescribing. A law passed in 2018 requires health benefit plans to cover pharmacist-provided services if, among other conditions, those services are provided in an area with a health-professional shortage. The health plan must pay pharmacists the same as they would licensed physicians and advanced practice nurses for the same services.
“Billing for services has allowed us to expand our services and help our community where access to these urgent care–type services are limited,” Smith said.
Progress, bit by bit
Although there may be payment laws in place in Colorado, it takes time for pharmacists to actually get paid for the clinical services, according to Emily Zadvorny, PharmD, CEO of the Colorado Pharmacists Society.
“In Colorado, we have seen a higher uptake of payment for services in settings where services already existed, like health-systems–based ambulatory care clinics,” she said. “In these instances, patient care services that were already occurring, like chronic disease management, can now be billed once the billing infrastructure in [electronic medical records] are updated and changed.”
Even though it’s less common, there are some community pharmacies, like Buena Vista Drug and Salida Pharmacy & Fountain, that have been able to obtain payment for services.
Smith said cash-based payment for clinical services has provided affordable and accessible care for those patients with insurance the pharmacy can’t bill.
In community-based settings, according to Zadvorny, some statewide protocols have been successfully billed for hormonal contraception, HIV PrEP and PEP treatment, and smoking cessation, which have been the most frequently used services paid by Medicaid.
Colorado’s law provides an opportunity for pharmacists to bill and be reimbursed for these nondispensing services—prescribing hormonal contraception or smoking cessation products—via statewide protocols. Since 2020, Colorado pharmacists have been authorized to prescribe and dispense HIV PrEP and PEP treatment under another established statewide protocol.
“We hope that this will soon expand to our statin protocol and our new [medication for OUD] protocol,” said Zadvorny. “Some community-based pharmacies and chains have been able to bill test and treat services to our state Medicaid program as well.”
Zadvorny said they are also working on revising Colorado’s existing payment laws to make it less restrictive.
“For Medicaid, in 2026, we will seek to broaden medical coverage to ‘anything allowed under our scope of practice,’ since it is currently limited in statute to coverage of visits provided under collaborative practice agreements or independent statewide protocols,” she said.
“For commercial insurance, we will seek to strike the health provider shortage areas and also introduce antidiscrimination language that will ideally help with enrollment and credentialing, by saying that if a health care service is covered by the health plan, and it is also allowed under a pharmacist’s scope of practice, that an insurer cannot discriminate payment based on provider type.”
Credentialing challenges
Once a covered benefit for patients has been authorized, pharmacists are able to enroll and be credentialed as plan network providers, then submit payment claims for clinical services.
In Colorado, Zadvorny said the Medicaid provider enrollment process has gone relatively smoothly for pharmacists, but not with private health plans.
“Often, a pharmacist trying to enroll and credential with an insurer will receive notices that pharmacists are not allowable provider types. Or the health plan will refer pharmacists to the pharmacy network process or PBM network, due to a lack of understanding,” she said. “Enrolling pharmacists as medical providers, independent from a physical pharmacy, is not commonly understood or engrained in health plans at this time.”
Surprisingly, billing departments within health systems have not fully understood the Colorado authorities for pharmacists either.
“There has been some resistance to adapting existing systems and understanding that this is an allowable revenue source, since it has not historically been so,” Zadvorny said. “We even had an instance of a billing department reversing charges for pharmacists’ services since they did not believe it was allowed.”
Leticia Smith, PharmD, director of ambulatory clinical pharmacy and population health services at Denver Health, Colorado’s primary safety-net health system, said billing for clinical pharmacy services has been a learning curve across the organization.
“While we have long-standing experience billing for Medicare Part D related services, expanding into billing for professional clinical pharmacy services has required significant education, iterative process development, and careful monitoring to ensure accuracy and compliance,” she said. “These evolving workflows have resulted in a start-and-stop implementation period, during which some revenue opportunities have been delayed and prevent us from knowing the true value of this work.”
Across the board, Zadvorny said education is still needed for all parties—pharmacists, health systems, and health plans alike. ■