On The Cover
Loren Bonner
Getting paid for patient care services has not been an easy road for pharmacists, but states continue to make progress, according to Allie Jo Shipman, PharmD, director of state policy at the National Alliance of State Pharmacy Associations.
“We’ve seen more success on the legislative front,” said Shipman. “But it’s not just waiting on legislative changes—it’s also reaching out to payers directly to figure out if pharmacists can get paid.”
Historically, states have established mechanisms for payment for pharmacists’ services by including coverage for services in state-provided health benefits or by mandating private insurers to provide coverage.
“Health plans have long partnered with pharmacists to help patients understand and be adherent to important medications for chronic conditions including diabetes, hypertension, and high cholesterol,” said Lynn Pezzullo, RPh, senior director of quality innovation at the Pharmacy Quality Alliance. “We now see stakeholders increasingly engage pharmacists to help patients control and improve blood pressure and A1C. We also see great interest in working with pharmacists to close gaps in adult immunizations.”
Improving patients’ health outcomes is a goal for all stakeholders across health care, according to Pezzullo.
But as more states gain traction with payment—and as many states have now waited years for full implementation of payment for pharmacists’ services—pharmacists are looking at the whole world of medical billing to understand how it’s different from pharmacy billing.
In order for pharmacists to receive reimbursement for their patient care services, they must first be recognized, credentialed, and contracted by payers in various networks. “It’s becoming a greater realization that even if you get [legislation] passed it doesn’t mean you get paid. It can take years,” said Shipman.
The payment evolution in states: spotlight on Washington, Wisconsin, and Colorado
All states recognize pharmacists as health care providers to some degree, but each state has its own path to full payment for pharmacists’ services.
Starting in 2017, pharmacists in Washington state began getting paid by private insurance for their services through a bill (SB 5557) signed into law in 2015 that made pharmacists in Washington providers in commercial health plans. Washington’s law is a payment parity law, which requires certain payers to reimburse pharmacists for a service for which other providers are reimbursed if the service is in their scope of practice. The law does not apply to self-funded plans. However, many self-funded plans, often those offered by employers, have elected to add pharmacists to their networks.
Washington pharmacists use medical codes, not pharmacy codes, to bill for patient care services. The most commonly billed codes are the evaluation and management (E/M) office visit codes. To bill the codes, pharmacists must apply to be in a provider’s network as a credentialed provider, sign a contract, and use medical billing software to document their visits and submit their claims, according to Jenny Arnold, PharmD, BCPS, CEO of the Washington State Pharmacists Association (WSPA).
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Table 1. HCPCS principal subsystems
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Level
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HCPCS
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I
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AMA CPT codes adopted by CMS
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II
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CMS developed codes, uniquely distinguishable beginning with
a letter followed by 4 numeric digits
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III
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Local codes, not presently in use
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There are 17 different HCPCS Level II code sets for everything from ambulance services to vision and hearing services. For patient care services, pharmacists may encounter “G-codes.” A common example is diabetes self-management training services.
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Because Washington’s law has been in effect for years now, pharmacists are not only being hired to work in clinics seeing patients, but more community pharmacists are being credentialed by private insurers’ health plans, Arnold said.
However, understanding the documentation structure and billing mechanism for medical billing can be a challenge for any health care provider. Arnold said the medical billing and documentation communication standards are different than the National Council for Prescription Drug Programs pharmacy standards. Medical billing is retrospective and involves a complex documentation structure with a billing mechanism. As opposed to pharmacy dispensing claims that are submitted and adjudicated at the point of care, medical claims are billed after the patient visit without verification of payment amount. After the health care provider provides the service and documents care, they may not receive payment for weeks.
WSPA holds regular calls with pharmacists who haven’t started billing to guide them through the process.
Arnold told Pharmacy Today in 2021 that it’s taken community pharmacies longer to “get all the pieces in place to make [patient care in community pharmacies] happen and for it to become mainstream.” Unlike clinics, they have to make more changes to workflow, software, and systems.
“More traditional billing software programs, which clinics and physician offices tend to use, are developing pharmacist subscription models to support care provided or administered in community pharmacies,” she said.
A few platforms are in development specific for the pharmacy setting, which can not only document care, but submit the medical claim for reimbursement, track the revenue, check a patient’s insurance, and more.
In Wisconsin, pharmacists are eligible to be reimbursed under the state Medicaid program for any service within their scope of practice, or any service delegated to a pharmacist by a physician that is typically reimbursable under the Medicaid program.
According to Sarah Sorum, PharmD, executive vice president and CEO of the Pharmacy Society of Wisconsin, they anticipate Wisconsin’s Medicaid program to go live with pharmacist medical benefit billing in early 2023.
“Pharmacists will bill similarly to other clinicians, either directly to the [Medicaid] program or through third-party billing software,” she said. “By billing on the medical side, pharmacists are able to bill for a variety of services that are not covered on the prescription benefit side, such as comprehensive medication management, diabetes, hypertension and anticoagulation management, medication administration, and more.”
Two-thirds of Wisconsin counties have areas considered medically underserved with significant gaps in health care. Pharmacist providers can help to address these gaps.
“By reimbursing pharmacists as medical providers, access to medication-focused services will increase both in the clinic and community settings,” said Sorum. Next, she said, they are eyeing discussions with private insurance partners and hope to use the success of Medicaid billing to drive those conversations forward.
Emily Zadvorny, PharmD, executive director of the Colorado Pharmacists Society (CPS), said scope of practice for Colorado pharmacists has been achieved, and payment laws have been passed and are being implemented.
As of 2021, Colorado has broad mandatory reimbursement under Medicaid for pharmacists practicing under a collaborative practice agreement (CPA), which includes statewide protocols that allow independent prescribing. Colorado law defines a CPA to mean either a traditional CPA or a statewide protocol—not separate authorities like most pharmacists are accustomed to. CPS was also successful in advocating for broad billing codes and parity of payment for pharmacists as enrolled medical providers. The new law requires Medicaid to pay pharmacists for these services if they enroll successfully as a medical provider.
In addition, another law passed in 2018 requires health benefit plans to cover pharmacist-provided services, if among other conditions, those services are provided in a health-professional shortage area (HPSA) and they would otherwise be paying for the same service if provided by a physician or advanced practice registered nurse.
Geographically, pharmacists’ ability to be reimbursed for services under commercial insurance in Colorado is nuanced. Across the state, commercial plans are allowed to reimburse pharmacists for any service, but must reimburse pharmacists for those same services if provided in HPSA areas.
“We are still working down the pathway to pharmacist credentialing in health plans,” said Zadvorny. Colorado has seen the most uptick in small health plans so far, as well as in the state Medicaid program. They anticipate more ambulatory care pharmacists, who are already engaged in CPAs, starting to bill.
“Ambulatory care pharmacists already practice in an environment where medical billing is done,” said Zadvorny. “They have this system set up, but often on the community side they are not set up to do [medical] billing.”
Several independent pharmacies, however, have had success billing Medicaid for health care services.
Zadvorny said having community pharmacists already enrolled in Colorado Medicaid as medical billers for vaccines should help speed up the process for these pharmacists to bill for the clinical services provided under statewide protocols or CPAs.
As the state pharmacy association, Zadvorny said CPS feels it’s their responsibility to help support pharmacists with medical billing, which can include everything from figuring out who the vendors are for medical billing to understanding the specific billing codes and how to document appropriately.
“Pharmacists will be subject to the same audits as any other provider. I want them to do all this successfully—use the right codes, right documentation—we will support those processes,” said Zadvorny. “We will use grant money to provide free training on how to enroll, how to get ready to get paid for these services, document appropriately, and bill appropriately.”
In addition to the established statewide protocols for hormonal contraception, smoking cessation, and PrEP/PEP, Zadvorny said they expect to add statin therapy for high-risk patients as a fourth statewide protocol once finalized by their state board of pharmacy as soon as this fall. Additionally, if pharmacists can get a CPA into place, they can get paid by Medicaid to do test and treat, and treat self-limiting conditions or those conditions that do not require a diagnosis.
Zadvorny said challenges exist in implementation. “For Medicaid, it is just a process of enrolling more pharmacists across the state, and spreading the word,” she said.
For commercial health plans, the challenge is getting them to enroll pharmacists as medical providers in their networks, credential them, and operationalize payment for services. Many large health plans across multiple states are still not operationalizing this on a large scale.
“Our scope of practice is very open, and although we have good payment laws, that part takes longer to implement. We are doing our best to keep forging our way down this pathway toward a more sustainable pharmacist and pharmacy business model,” said Zadvorny.
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Table 2. Examples of HCPCS Level II G-Codes representing common pharmacist-delivered patient care services
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HCPCS G-Codes
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Professional services
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G0108
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Diabetes outpatient self-management training services; individual; per 30 minutes
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G0109
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Diabetes outpatient self-management training services; group session (two or more); per 30 minutes
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CPT codes are 5-digit codes developed and maintained by the AMA Current Procedural Terminology Editorial Panel to standardize communication between health care providers and health payers. Even when billing for services is unavailable, these codes can be used to document services and help quantify the contributions that pharmacists make to patient outcomes within a practice or organization. Each code corresponds to a specific description of a service or procedure (medical, surgical, diagnostic).
There are 3 pharmacist-specific CPT codes (99605, 99606, and 99607) used for the delivery of MTM services and recognized by some Medicaid and private health insurers. Pharmacists also use various CPT codes commonly used by other providers for different types of services. For additional information about these billing codes, consult CMS for HCPCS Level II and AMA for CPT codes.
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Medicare reimbursement
Besides state programs where pharmacists are directly recognized by a payer, there are also other ways pharmacists can get paid through provisions in Medicare. Pharmacists can work directly with physicians under financial arrangements where the physician bills Medicare for the pharmacists’ services.
Since pharmacists’ services are not included in the Social Security Act under Medicare Part B—the part of Medicare that covers outpatient health care professionals—pharmacists cannot directly bill for patient care services.
But Medicare Part B policies do permit physicians and other qualified nonphysician practitioners (NPPs), such as physician assistants and advanced practice registered nurses, to bill for pharmacists’ services under ‘incident to’ physician services arrangements using the physician’s or NPP’s national provider identifier. Incident to services billing may also be permitted by state Medicaid programs and commercial plans.
Many pharmacists around the country have successfully partnered with physicians—either by being directly employed with a physician practice or by contracting with one or more physician practices to provide services. Many physician practices are trying to meet outcomes required by new value-based payment models, and pharmacists are brought in to help them meet those quality metrics.
Most pharmacists in these arrangements are spending their time performing chronic care management services (CCM) and transitional care management (TCM), which are generally non–face-to-face visits, but pharmacists can also see patients in person for E/M services and annual wellness visits, which are also reimbursed by Medicare.
With CCM, a CPA does not need to be in place, only a contractual agreement with a qualified health care provider. Additionally, a pharmacist does not have to be in the health care provider’s office to perform CCM or TCM. The physician or NPP could bill for their time spent on the phone with a patient or the work done coordinating the patient’s care. This might mean communicating with the provider, for example.
As defined by CMS, eligible CCM patients who qualify for the service must have multiple (two or more) chronic conditions expected to last at least 12 months or until the patient’s death. Pharmacists can work with patients whose conditions range from diabetes and heart disease to dementia and Alzheimer’s. Because CMS offers billing codes for not only noncomplex but also complex CCM, which allows for more clinical staff time, there’s also flexibility in how much time they can spend with a patient.
Outside of this opportunity within the Medicare program, CMS also contracts with prescription drug plans (PDPs) to administer MTM for beneficiaries as a quality improvement program. PDPs determine the construct of their MTM programs but are not required to contract with pharmacists to deliver MTM services. Therefore, in the Part D program, CMS does not contract or pay pharmacists directly for their services.
State-level payment “buckets”
Public payers, such as Medicaid: Arrangements with public payers to provide reimbursed services that meet a public need or reduce treatment costs for patients at highest risk. Can apply to a comprehensive set of services or a few discrete services (e.g., medication therapy management, smoking cessation counseling, hormonal contraception furnishing, HIV pre-exposure prophylaxis, HIV postexposure prophylaxis); can apply to all beneficiaries or only beneficiaries who meet certain criteria (e.g., those who live in an underserved area).
Commercial payers: Arrangements to provide services to all or some plan members. In some cases, pharmacists can bill per service provided; in others, the pharmacist is paid a set fee per member per month. Credentialing may be required to bill commercial payers—each payer can set forth its own requirements. Payers may cover a comprehensive set of services or limit coverage to specific services.
Private employers: A business partners with a pharmacist to provide care to its employees and their dependents.
State employee plans: Arrangements to reimburse pharmacists for services provided to individuals employed by the state, particularly around chronic disease management. The state has discretion on plan design.
Federal legislation
Medicare—the largest federal health care program—does not currently recognize pharmacists’ services for payment.
“Across the country, many state Medicaid programs and commercial health plans often look to the federal government and the Medicare program in setting their policies regarding payment for pharmacists’ services,” said Anne Burns, RPh, vice president of professional affairs at APhA. “The fact that Medicare does not recognize pharmacists and their services is a significant barrier to payment in all of the other sectors, including value-based models with fee-for-service components.”
Studies have shown that pharmacist involvement in patient care can reduce hospitalization rates and inpatient costs. Patients are 3 times more likely to stay out of the hospital when pharmacists provide clinical services after discharge. A 2019 article in JAPhA found that a novel pharmacist-run program focused on preventing adverse drug events generated up to $319 in cost savings per medication review.
Even federal bodies like the U.S. Public Health Service recognize the value of pharmacists’ patient care services. They wrote that their research data from a 2019 study “Demonstrate the ability of advanced practice pharmacists in multiple locations within the federal sector to improve targeted clinical outcomes in patients with varying diseases.”
Despite these data and more, pharmacists still struggle to be recognized as providers on the federal level and get adequately paid for their services. Two bills in Congress right now could change that, however.
Currently, a pharmacy coalition is working to get the Equitable Community Access to Pharmacist Services (ECAPS) Act (H.R. 7213) passed in Congress. Another bill, the Pharmacy and Medically Underserved Areas Enhancement Act (S. 1362/H.R. 2759), introduced in 2021, is also in play. ■
See www.pharmacist.com/Advocacy/Issues/Provider-Status to find out more about these pieces of legislation.
Medical benefit vs. pharmacy benefit
New payment opportunities raise new considerations for pharmacists, especially those working in community pharmacies: Is the patient care service covered under the patient’s medical benefit or the pharmacy benefit?
The pharmacy benefit, administered by PBMs, covers dispensing services and various other related patient care services, such as administration of some vaccines. The medical benefit, on the other hand, is administered by health plans and is the pathway used for billing patient care services by other health care providers.
The billing pathway for a patient care service is determined by the type of payer covering it—the health plan or the PBM. Services covered under the medical benefit are submitted as a medical claim to the health plan while services covered under the pharmacy benefit are submitted as a pharmacy claim to the PBM.
Pharmacists are well acquainted with eligibility checks and claim adjudication as part of dispensing services. When billing to the pharmacy benefit, these checks are conducted in real time, and pharmacists immediately see if the patient is eligible for coverage and if they will be reimbursed for the claim. But when billing to the medical benefit, eligibility checks and claims adjudication do not happen in real time, although steps are being taken to try to change that.
When pharmacies submit a pharmacy claim to the PBM, the claim is transmitted under standards of the National Council for Prescription Drug Programs (NCPDP). Current NCPDP standards accommodate the submission of information applicable to a dispensed medication (e.g., medication name, quantity, day supply, and NDC, etc.) and some elements of the data for patient care services.
Medical claims are submitted via Health Level 7 standards, which can accommodate a wide array of data for various clinical services and procedures. For medical claims, pharmacies often engage a medical intermediary to add required elements of the data and transmit the claim to a health plan.
Although there are many different aspects to consider with each billing pathway, APhA generally supports coverage and billing of pharmacists’ patient care services under the medical benefit. The profession’s Medicare Part B provider status efforts are targeted for recognition and coverage of pharmacists’ services in the Medicare program under the medical benefit. Also, coverage under this pathway in federal, state, and private sector programs places payment for pharmacists’ services in the same place as all other health care providers. Additionally, coverage under the medical benefit can be applied across various practice settings, including community pharmacies. ■
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Table 3. Distinguishing characteristics between the medical and pharmacy benefits
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Medical benefit
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Pharmacy benefit
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• Claims submitted to the health plan as a medical claim.
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• Claims submitted to the PBM as a pharmacy claim.
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• Electronic submission format falls under the Health Level Seven (HL7) standards, can accommodate a variety of different types of data for the claim.
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• Electronic submission format falls under the NCPDP standards that currently best accommodate prescription claims data and have some fields for patient care services, such as medication administration for vaccines, but lack the ability to include many clinical data fields for patient care service billing.
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• Eligibility checks and claims adjudication are not conducted in real time.
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• Eligibility checks and claims adjudication are conducted in real time.
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• Health plans credential individual providers, including pharmacists, as network providers.
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• PBMs credential pharmacies.
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• For medical claims submitted from a pharmacy, a medical intermediary often needs to be engaged to add required data to the pharmacy claim to meet medical claim requirements.
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