Tuesday, October 5, 2010

State of the profession.....Reimbursements Part II

A couple years ago I was working for a regional grocery chain. That was back when NPIs were just starting to be issued. Our director of pharmacy operations encouraged each pharmacist to get their own NPI.

At that time, it was explained to us that all billing for medical services were switching to the NPI as the only recognized identifier. NCPDP numbers would no longer be used in pharmacy transmissions. Physicians would not be identified by their UPIN or DEA, but by their NPI.

So it makes no sense to this pharmacist that individual pharmacists are not able to contract with insurers because, get this, they only issue contracts to providers who have NCPDP numbers.

And what is even better is that the NCPDP will not issue numbers to non-dispensing locations or individual pharmacists. In simpler terms, the NCPDP will enter into a contract with a building (the pharmaCY) but not the health care providers inside the building (the pharmaCISTS).

If pharmacists want to get reimbursed by insurers for other-than-dispensing services, we need our organizations to get us recognized as providers based on our NPIs (the supposed standard for medical billing).

* * * * *

We pharmacists provide many services for our patients at no charge. On any given weekend I consult with at least four patients every hour. Either to recommend an OTC item or triage an injury that they have sustained. With the way that the current system is set up, I can't bill for these services because pharmacists are not recognized as medical providers. The recommendations that I make on the weekends may save the insurer the costs of an unnecessary ER visit, but there is no system to document these interventions for the insurers.

I would love to be able to bill for these interventions. Then the patients would be able to see how much our professional services are worth. The insurers could see how many visits to the ER were avoided due to pharmacist intervention. We will see some reimbursements for our services.

If we can show our value in this scenario, maybe it will open the doors to being able to bill for MTM services. If insurers see how much money we can save them in acute situations, they may be more open to our services for patients with chronic conditions.

There are a couple issues that could complicate this, which I may discuss if I do a post in the future on insurers. But for now we need to open our minds to the thought that we should be billing for and getting reimbursed for every consult we provide. All we would need to do is make a copy of the medical insurance card, fill out a short SOAP note on the encounter, and bill.

Pharmacy organizations, consider this to be your assignment for the next three months and show us some progress.


Pharmgirl said...

I like this idea, however, I can see a problem that I hope you will address. Many of the consults we do come from patients with no insurance. They often turn to us because they can't afford a doctor visit, or don't want to spend the money. Are we to start charging them for our advice? "Here's the correct dose of Tylenol for your infant based on weight. That will be $5." It will be difficult to get the public to cough up. I understand that it would show patients that our services have value, but I think they will be less likely to ask questions if they have to pay. If we don't charge our uninsured patients, then I don't know how insurance will reimburse us for something we give away to others as "free." Any thoughts on this?

PAS said...

A very good point, involving a complicated issue.

The transition from DEA, State License numbers, and NCPDP numbers has been quite rough and not exactly uniform. I can't count the number of times I've requested an NPI from a physician's office only to get the response, "What's an NPI?" - a frustrating answer when its coming from an office that principally bills Medicaid or Medicare patients. Likewise, I've had to troubleshoot claims out of a retail pharmacy where it has turned out that the last several years they've submitted all their claims under their NCPDP # - while in theory, NPI should be used, the fact of it is in most cases NCPDP #s will frequently still be accepted.

As for the billing of pharmacist services, another very good idea overall. The experience and skills of the pharmacist are one of the most incredibly overlooked resources in the healthcare field. Anyone working in the retail field can recount daily incidents of physicians writing nonsense scripts: oxycontin q4h, pill splitting of controlled release drugs, significant drug-drug interactions especially through CYP450s.

One of the big barriers I see to billing for services provided is that such services would typically be billed with CPT/HCPCS codes. Pharmacy software and claims adjudication is absolutely incapable of dealing with such things - they have little to no role in outpatient pharmacy. A sort of stopgap is that there is a Level of Service field. In most circumstances, this is neglected and nonfunctional. However, there's no reason that services couldn't be incorporated into pharmacy network contracts, and reimbursements issued based on the submitted value in this field. However, it's not a particularly robust means of billing.

lovinmyjob said...

The whole NPI vs. NCPDP (formerly NABP) is a joke. How many times each day do you call a 3rd pary help desk and instead of asking for your NPI they ask for your NCPDP? I asked one rep about this once and was told that "its just easier to ask for a shorter number". Wow, its what a whole 4 digits shorter!! Then occassionally I've even had help desks ask for my tax-payer ID number! That took some searching to find that puppy!
As far as billing for our services all I can say is that we as a profession have shot ourself in the foot on that one. By working for corporations rather than ourselves what does it matter? If we did bill and get reimbursment the money would go to corp anyway. Not to mention the fact that corp could "order" us to give our services away for free and we would have no recourse. If Joe-Blow-Mega-Retailer down the road gives it away then everyone would have to in order to stay competitive. (Can everyone say $4 generics?) My pharmacy does MTM and TIPS billing, which is a pain in the butt, however corp gets the fee not the pharmacist. Bottom-line: the majority of us are EMPLOYEES. Our free advise is right up there with the weekly ad items that just draw people into the store so they will buy more product. Cynical but true.

Anonymous said...

Lovinmyjob summed it up, we turned our profession over to mba's and gave the profession away. We are not the captains of our ship and would end up right where we are, giving our services away, pharmacy as the loss leader, so corp. can sell more lawn chairs. For the most part, pharmacy getting taken seriously or paid for our knowledge seems like so much pie in the sky.