Five Steps Pharmacies Should Take to Receive Reimbursements for Clinical Services

By Tara Pfund, PharmD, Product Manager, AssureCare

Pharmacist roles as caregivers continue to expand. These highly trained, trusted clinicians are a vital component in caring for patients across their community. I have discussed and blogged about this topic on many occasions, and I recently had the honor of providing a continuing education lecture about this during an Oregon State Pharmacy Association event.

During my presentation, “Implementation of Reimbursable Pharmacy Clinical Services,” I discussed how pharmacists’ roles as caregivers is evolving beyond traditional medication dispensing into medication therapy management, preventative counseling, tobacco cessation services, etc. While pharmacist’s scope of work is expanding, what is lagging is reimbursements for the clinical services provided. This topic is near and dear to my heart, and a key driver of my “why” in the work that I do at AssureCare. There are several factors at play that are preventing pharmacists from obtaining reimbursements for their services:

- Lack of resources explaining steps required for the pharmacy to implement clinical services – especially as a billing provider

- Absence of covered services transparency, charting requirements, credentialing, and enrollment steps

- Shortage of successful models that showcase consistent reimbursement from medical payors and validation of staffing/workflow models in the pharmacy enabling consistent service delivery

- Inconsistencies in state and federal agencies recognizing pharmacists as qualified care providers, which services are permitted, and payment parity laws requiring health plan payment for pharmacist providers

- Inadequate training, lack of technology, limited payor credentialing/documentation, and staffing shortages that are also preventing pharmacist from billing for clinical services provided.  

Despite these many obstacles, the time is now to launch into the next generation of pharmacy billing. Here are five steps pharmacists can take for successful reimbursement of clinical services:

1. Set-up Credentialing and Enrollment. Identify who are the top medical payors for your patients determine their requirements for credentialing and enrollment. Complete provider applications and required contracting steps.

2. Find a Technology Solution that Supports Clinical, Administrative, and Financial Needs. Pharmacies must find a software solution that serves their unique needs and enables them to support medical billing and documentation for all services provided during the visit (even if beyond initial chief complaint) and workflow needs of the pharmacist. An ideal solution is an ONC-Certified Electronic Health Record (EHR) which will foster interoperability, is customizable to meet state regulations, provides access to clinical information, offers role-based task design, and integrates with medication dispensing solutions.

3. Training. Provide and complete adequate training for your staff (Tip: Focus on your technicians!) on:

- Claims submission requirements

- Service, state, or protocol requirements

- Company policies/procedures, workflow, and documentation steps

- Billable professional services, such as patient assessments, contraceptive education, emergency refill of insulin, Opioid overdose prevention, and tobacco cessation counseling.

4. Perform Visits and Submit Claims. Leveraging the processes, training, and technology outlined in steps 1-3, now is the time to put into action all the hard work leading up to this point. Following the Joint Commission of Pharmacy Practitioners (JCPP) recommended Pharmacists’ Patient Care Process, pharmacists now have the foundation, strategy, and tools to successfully bill for clinical services offered. Often a patient’s initial reason for visit, for example tobacco cessation, expands into additional clinical encounters such as blood pressure management or supporting persistency to medication regimens. Ideally your documentation platform enables billing for all services rendered, as seen in other healthcare settings, enabling maximum reimbursement potential.

5. Access and Optimize Revenue Cycle Management. The final step is to review and access RCM reporting and services to ensure pharmacists are capitalizing on reimbursements for billable clinical services. This involves confirming claim transmission, monitoring through rejection and denial management, and following up on claims until successful payment is received.

Implementing these five critical steps, can equip pharmacists to successfully receive reimbursements for billable clinical services. I am proud and honored to continue moving the needle in making this “new” pharmacy practice model a reality.

Interested in learning more or discussing further? Connect with us today.