State of the Profession.... Reimbursement Part I

For years, we've seen declining reimbursements for the product that we dispense. I've addressed that in a previous post and I don't really want to discuss that in my state of the profession series. I'll just say that pharmacy benefits managers should select one reimbursement formula and stick with it for the term of a contract.

Today I want to discuss reimbursement for the professional services that are provided by pharmacists. As the system exists now, pharmacists are not even recognized as providers by health insurers. I checked the websites of several insurers in my state (Ohio) and did not see a single instance of a pharmacist being recognized as a health care provider.

This is where the organizations that represent pharmacy need to get on the ball. For years we've been hearing about how pharmacists are able to decrease expenses and improve patient outcomes.

Well good for us. But that's not good enough. We need recognition as individual health care providers so that we can bill for the interventions and services that we provide. The organizations that I mentioned in my last post need to forget about showing the value of pharmacist services and get us recognized as providers. If pharmacists are able to bill insurers directly for services, you'll see a lot more pharmacists get on board. Money is a motivator.

A few years ago, the company I worked for wanted each pharmacist to get their own NPI. At the time I didn't think much of it. Now I can see the importance of your own NPI. If pharmacists are able to bill for the professional services that pharmacists provide, I want the reimbursement to come to the pharmacists, not the pharmacy. The pharmacy is just a building.

Right now pharmacists are able to bill for three CPT codes....three. All tied to medication therapy management services. The organizations that represent pharmacy need to get us more recognized services and codes so we can show all of the services that we provide.

The way the system works now, when I show a newly diagnosed asthmatic patient how to use their nebulizer, peak flow meter, inhalers, etc... I'm doing so basically out of the goodness of my heart. The $1.75 dispensing fee on the prescriptions doesn't cover the 15 minutes that I'm going to take to educate the patient. The same goes for diabetic patients and their glucose monitors and education on how to use their insulin delivery system. We need billable codes (that are unique to pharmacist services) so we can be reimbursed for the specific educational services that we provide.

And just like physicians are able to have patients come back in for follow-up visits to check BPs after starting a patient on a new medication, we should be able to bill for follow-up services to make sure that the patient is using their medical devices correctly. Or following our prescribed therapy. Or whatever service we have provided.

For the dispensing pharmacist, there should be reimbursement for the professional services provided on each and every prescription. We should be able to bill for all of the DURs we do. Of course we would need to document a little bit more, but it would reinforce the fact that we are providing a professional service on each and every prescription. The documentation process would use our individual NPIs to direct where the reimbursements would go.


The take home message today is this....pharmacy organizations, you need to stop worrying about showing the value of our services and get us recognized as individual health care providers. Pharmacists, you need to recognize that you provide unique professional services and should be compensated accordingly for these professional services.





More to come on reimbursements in my next post.