Don’t Miss Out on New MTM Opportunities

by Ashley Keller, CPhT, OmniSYS Partner Relationship Manager

Medication therapy management (MTM) is one of the oldest clinical services in the pharmacy – many pharmacies have been performing MTM for at least 15 years. You know the drill: sign up to get connected with Medicare Part D patients, perform one MTM annually per patient, get sent reimbursement minus some fees.

But something has changed in the past few years. State Medicaid and commercial payers have taken notice of the opportunity, and they are actively reimbursing pharmacists for MTM directly. You will have to spend a little time getting set up to start engaging in these non-Medicare Part D MTMs but the upside is that there is a significant revenue opportunity for some of the reasons I’ll outline below.

Here are some very practical steps to take advantage of these newer MTM opportunities.

1. Understand the opportunity

So, what is the real value of the opportunity here?

Let’s use Michigan Medicaid as an example. The state of Michigan has approximately two and a half million patients who are on Medicaid, many of whom qualify for MTM. That means there are hundreds of thousands of eligible MTM patients in Michigan who are not covered by traditional Medicare Part D MTM programs.

Michigan Medicaid has made it easy for pharmacists to enroll as providers and seek reimbursement for MTM services. Michigan Medicaid will also reimburse for multiple MTM encounters annually as opposed to a single annual encounter (many other Medicaid and commercial MTMs reimburse for multi-encounter events as well). Apply some simple arithmetic here and you can quickly see how the opportunity could be exponentially more than with traditional Medicare Part D MTMs.

I used Michigan as an example, but there are a number of similar programs in other states and run by different commercial payers, which leads us to the final step in understanding the opportunity: find out which payers cover MTMs in your area (the OmniSYS Training Center can help, with a comprehensive list of payers covering MTMs by state).

2. Get credentialed and contracted

I can hear your deeps sighs through the computer on this one. Yes, this process does take some time (and you can read more about it in our recent MythBusters! Credentialing and Contracting blog), but it will absolutely be worth it based on the revenue opportunity that’s at stake.

The good news is that the MTM opportunities with state Medicaid generally have a straightforward credentialing and contracting process. The other good news is that Medicaid will accept any qualified provider, whereas commercial payers are often more selective. The OmniSYS Training Center will walk you step-by-step through the process of enrolling, contracting and credentialing with the payers you select, or you can research this information yourself by reaching out directly to the payer.

3. Find a solution to facilitate the process

There is not a central provider that manages the process for you here like there is for Medicare Part D, which means you need to seek out your own solution to help you facilitate the process.

Here are is what a solution should include:

  • Guided documentation to ensure you are documenting all the necessary elements for reimbursement based on state and payer requirements
  • Ability to bill the encounter as a medical claim
  • Option to share the encounter with other providers

If you want to start expanding your clinical services offerings but aren’t sure where to start, Medicaid and commercial MTMs are a great next step. The Strand-Rx Medication Management module can also help make the process easier by facilitating the entire MTM process with Medicaid and commercial payers. By following the steps outlined above, you can leverage your existing MTM knowledge to take advantage of this profitable opportunity.


Ashley Keller, CPhT, OmniSYS Partner Relationship Manager 

In her role as partner relationship manager at OmniSYS, Ashley Keller works to develop strategic relationships within the pharmacy industry that advance the role of pharmacists as providers. Ashley is also a certified pharmacy technician (CPhT) with expertise in store operations, customer experience and team member engagement. Prior to OmniSYS, Ashley managed pharmacy and retail operations at Walgreens.

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