From Staffing to Billing: Is your Pharmacy Ready to Expand its Clinical Services?

In today’s environment,  patients are seeking easier access to basic healthcare services. The prevalence of care deserts – in rural and urban regions alike – signal the shrinking physical footprint of traditional physician-delivered care.  What does this trend tell us about the future of your pharmacy? Quite a lot, actually.

Pharmacies provide an ideal location for test-to-treat services related to chronic conditions – as well as chronic condition management. They’re staffed by credentialed, licensed clinicians. There are more than 60,000 of them. And 88.9% of the US population lives within 5 miles of a pharmacy (48.1% within only 1 mile). Better yet, there’s pending federal legislation supporting the expanded role of pharmacists in delivering clinical care. The good news: Pharmacies are well positioned to expand the range of services they provide their communities. Many already have.

As you consider the merits of expanding clinical services, it’s helpful to take an honest assessment of your pharmacy’s current position and state of readiness. A few key considerations:

  • Regulatory environment – Take inventory of current federal, state, and local regulations. Do they permit services that your pharmacy doesn’t offer today? Then take it a step further and read up on trends and pending legislation. Can you align your pharmacy to offer everything currently allowed, while laying the foundation for new opportunities?
  • Geography – Note nearby locations where customers might opt to receive care, such as clinics, hospitals and, of course, other pharmacies. How will your pharmacy fit in? How will you differentiate your services from other options?
  • Staff capabilities –Evaluate your current team’s capabilities and workload. Can they take on additional patient-facing duties? Do you need to realign responsibilities or offload certain tasks to other team members? Do you need more people?
  • Community health needs – You and your team know your customers. You talk to them every day. What worries them? What medical concerns bubble to the top? And are there broader community needs that remain unmet? Aligning your practice to meet those needs provides the dual benefit of adding revenue, while heightening customer loyalty – because you’ve shown that you’ve listened to them. You’re giving them what they need.
  • Reimbursement – Weigh your reimbursement strategy. How are you billing now, and how will you bill for future services you provide? Is the process working, or are there gaps and pain points? If you add new offerings, will your current model scale to ensure adequate reimbursement?

Billing Strategy - A Closer Look

As you look to expand services, your billing and reimbursement strategy will play a critical, foundational role. A successful strategy, coupled with an efficient revenue cycle management process, empowers you to meet the needs of more patients while maintaining – and even enhancing – profitability. And there are two primary approaches you can take.

When it comes to filling prescriptions, pharmacy billing makes obvious sense. It’s comparatively simple. It operates on a product-centric infrastructure. It’s optimized for volume. It provides almost instant determination of eligibility and adjudication. And it’s familiar.

Medical billing is optimized for providing clinical care and service – as opposed to physical products. Under the pharmacy billing model, any consultative services would be associated with a corresponding pharmacy claim. Medical billing, however, relies on provider visit CPT codes. It does not need to be attached to a product claim for reimbursement. As a result, it enables pharmacists to bill for a wider range of services – while opening the door for higher reimbursement for clinical services.

If you haven’t already, incorporating medical billing in your reimbursement strategy can seem especially daunting. On the surface, it can seem as though it would create a more time-consuming, process-intensive revenue cycle while heightening the risk of not being reimbursed. In the long run, however, it can pay off, ensuring you receive adequate reimbursement for such pharmacy-provided clinical services as:

  • Immunizations
  • Diagnostic testing (including COVID-19, flu, strep, UTI)
  • Diabetes self-management training (DSMT)
  • Medical nutrition therapy (MNT)
  • Birth control consulting
  • Oral anti-cancer, immunosuppressive and respiratory drugs

Where do you Take Your Pharmacy

If you’ve evaluated the current and future landscape and determined that expanding clinical services makes sense, make sure your reimbursement strategy will support it. After all, the added value you provide your community, as well as the additional revenue it provides, is sustainable only if you have the revenue cycle processes to support it. Even if you’re already providing some – or all – of those services – giving your billing strategy a closer look can pay off in the long run. And if incorporating medical billing seems complex and intimidating, there are resources and technology to alleviate complexity, helping you derive the maximum value from the services you provide.

For an in-depth comparison of pharmacy and medical billing – including guidance on evaluating the two approaches and implementing the one that works best for your pharmacy – download our white paper:  As Pharmacies Provide More Clinical Services, What’s the Right Approach for Billing and Revenue Cycle Management.

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