For all my 32 years in the profession, pharmacists have been asking for the right to bill third-party payers, namely major medical insurance companies, (e.g., Medicare, Medicaid, and commercial) for their care services. We’ve had fits and starts, and in some states the uptake has been good because in large part the state pharmacy association has done tremendous work to make the processes of becoming an in-network provider easy to understand and navigate.
But the harsh reality is that pharmacists are not signing on as covered providers and billing for their services when they have the authority and opportunity to do so. It is time for our profession to lean into the opportunities in front of us and take advantage of them. It is time for all of us to lead where we are planted and grab ahold of the opportunity.
As of June 2024, a total of 36 states have passed laws mandating coverage of and payment for at least one or more pharmacist service either through the state’s Medicaid program or by commercial insurance.
While we know that some are taking steps to become a covered provider and are delivering the services, billing isn’t happening. We’ve heard pharmacists claim, “I can’t get paid for my services.” and commercial insurance say, “We aren’t getting any requests for payment from pharmacists.” or “we can’t get enough pharmacists to do the service.” We’ve also heard that the process of medical billing is too complicated, and pharmacies are choosing a cash-only approach.
APhA is working closely with other organizations and a host of major medical insurers to work through the admitted complexities. In the meantime, there are some important action steps that can be taken quickly to address the issues pharmacists are facing in the states where pharmacists are authorized to bill for services.
Two steps
In order to submit payment claims to a medical insurer (payor), there are usually two steps that pharmacists need to complete before they can successfully bill for their services. The first step is provider enrollment. The second step is provider credentialing. Confused about the difference between the two? You’re not alone! Provider enrollment and provider credentialing are closely related. Provider enrollment is the process of establishing the provider’s eligibility to submit claims to a payor. Provider credentialing is the process of verifying a provider’s competence and qualifications to provide services. Provider credentialing is usually a part of the provider enrollment process.
Provider enrollment
The steps that you, as a pharmacist, need to take to enroll as a provider with a payor will depend on whether you are contracting directly with the payor, or whether your employer (e.g., pharmacy, health-system, physician’s office or clinic, etc.) is contracting with the payor.
If you are working directly with a payor, you will need to complete the paperwork required by the payor to become enrolled as a provider.
If your employer is contracting with the payor, your employer has likely already established a contract to provide services to patients and be paid for those services. In this instance, it will then fall on you to be credentialed to demonstrate that you are qualified and competent to provide services to patients.
Credentials
Some payors require direct credentialing, meaning the pharmacist must be credentialed by the payor before you are eligible to provide services and bill for them under your employer’s contract with the payor.
Alternatively, some payors allow employers to perform delegated credentialing. Under the delegated credentialing model, your employer is responsible for ensuring that the employees who are allowed to provide services for patients possess the qualifications and competencies outlined in the agreement between your employer and the payor.
The provider credentialing agent for most health care providers is the Council for Affordable Quality Healthcare (CAQH). Many, but not all, health plans accepting billed services will require a completed CAQH application. The profession is working toward National Committee for Quality Assurance (NCQA) accreditation and partnership with CAQH so that Pharmacy Profiles (the pharmacist credentialing organization) is the provider credentialing organization for our profession. Claiming a profile for credentialing with Pharmacy Profiles is free (pharmacyprofiles.com) and every pharmacist needs to take this first easy step.
Billing
Pharmacists need to establish the necessary systems to facilitate medical billing. APhA advocates for pharmacists to be treated as equals with other providers (i.e., provider parity) and we encourage pharmacists to use the processes and procedures that match those used in medical practices. We need every pharmacist to bill, regardless of practice setting. Read more about this subject in my Pharmacy Today editorial from earlier this year.
Consider having a billing and coding expert designated on your staff—perhaps a pharmacist, but this role could also include a PTCB-certified pharmacy technician or a certified professional coder (yes, there is such a person). In simple terms, you must understand how service-based billing occurs.
Admittedly, all this information may seem overwhelming. APhA, and your state pharmacy association, are here to help with support. APhA has created a medical billing primer for members, offers a certificate program to get paid for services, and has common acronyms and terms defined via a learn-the-lingo practice resource.