by David Pope, CDE, PharmD, Chief Innovation Officer
Due to the downward market pressure in the pharmacy industry today – and in order to stay successful long term – pharmacies must diversify their business model beyond dispensing. Most pharmacies have already taken the first step towards a more diversified business model by providing immunizations. This model has been incredibly successful, both for patients who now have a more convenient setting of care to receive vaccines and for pharmacies that receive a high ROI from providing this service.
If your pharmacy organization is solely focused on immunizations, however, you are potentially missing out on high-value clinical services that are actively being reimbursed by payers. Every pharmacy has the opportunity to improve patient care and increase revenue through clinical services. Many pharmacies already provide clinical services that they may be reimbursed for after establishing a relationship with a payer or can begin to offer those services with the proper training.
So, why aren’t more pharmacies involved in clinical services beyond immunizations? Reimbursement for clinical services varies by state and payer, plus understanding the different credentialing and training requirements can be overwhelming. Navigating the clinical services landscape takes focused attention but the process is not nearly as difficult as it seems. Thankfully, there are a number of resources that can assist you in your journey.
Navigating the Clinical Services Landscape for Pharmacies
Determining which clinical services to engage in at your pharmacy starts with understanding which services are allowed in your state, defining payers that reimburse for each service and determining the credentialing and contracting process with payers. Fortunately, there are organizations that have taken the guesswork out of each of these potential barriers, allowing a smooth process for those ready to engage in clinical services.
When you are looking for the right resource to help you understand the clinical services landscape, look for these key aspects:
- A list of clinical services that pharmacists can provide in each state(s). This is influenced both by state law and payer acceptance.
- The necessary accreditation steps your pharmacy needs to provide certain services.
- Access to training and credentialing requirements for pharmacists.
- A list of payers within your state(s) that will reimburse for each service as well as CPT codes.
- Links to the necessary documentation for payer contracting.
How Pharmacies Can Leverage Technology to Expand Clinical Services
Once you determine which clinical services to pursue in your pharmacy, it’s imperative you build the right infrastructure to support the documentation and reimbursement of these services. The good news is there are technology solutions for electronic documentation that will streamline your workflow and ensure that you’re capturing all the information necessary for proper reimbursement. Leveraging technology in this area will put the right guardrails around your clinical services program to ensure that you are capturing all the information needed for reimbursement.
It’s also important to note the majority of clinical services are billed in the same way that medical claims, not pharmacy claims, are submitted. You’ll need to ensure your documentation technology also provides a way to bill medical claims and sets proper guardrails to ensure high collection rates. Thankfully paper documentation and paper-based claim forms are a thing of the past.
Emerging Clinical Services to Watch
Requirements vary by state and payer; however, there are few key clinical services that are rapidly emerging and quickly expanding to additional states.
There are a myriad of clinical services you can offer in addition to the four listed above, such as Medication Therapy Management (MTM), pharmacogenomic counseling and more. Once you select the clinical services that best fit your patient population and your organization, start the process as soon as possible. Completing the credentialing and contracting process with a payer for a medical benefit can take an average of three months or longer.
Summary of Findings
The pharmacy industry is moving towards enhanced clinical services, and now is the time to start laying the groundwork to support these services in your pharmacy. There are foundational requirements, such as credentialing and contracting, that will be required regardless of the clinical service you select. Pharmacies that are able to capitalize on this trend early in the process will reap numerous benefits including competitive differentiation, and will propel their organization forward in the new landscape.