Getting Reimbursed For Clinical Services: 4 Things You Need To Know

Rules and regulations affect every industry, and pharmacy is no exception. As the role of pharmacists continues to evolve and expand, so do the requirements that allow them to act as essential, frontline caregivers in an ever-changing healthcare landscape.

The ability to perform clinical services is managed at the state, and occasionally the national, level. And we’ve seen incredible progress in that area, especially in the past 18 months. For example, pharmacists in a number of states have the ability to prevent, test and treat illness like flu, strep and soon COVID-19. Pharmacists in any state can now administer vaccines to kids over the age of three. Pharmacists in 24 states and counting can prescribe hormonal contraceptives. And the list goes on and on.

But getting paid for performing these services is a different animal. In the case of reimbursement, payers treat you like any other provider. And with that comes payer-driven standards for providing services, generally called credentialing. Once credentialing standards are met, pharmacists also have to be contracted as a provider with each payer they want to bill.

As provider status expands and pharmacist-administered clinical services become more prevalent, understanding how to manage pharmacist credentialing and contracting is critical to a profitable clinical services strategy.

When it comes to credentialing and contracting, here are four key considerations:

1. Payers Generally Allow Individual Providers into Networks, Not Organizations

Today, pharmacies operate on an organizational level when it comes to contracting and reimbursement. That means it doesn’t matter if pharmacist A dispenses the drug vs. pharmacist B, your relationship with payers around reimbursement is at the pharmacy level.

When you move over into the clinical services realm, everything changes. For the most part, pharmacists must be contracted and credentialed as individuals with any payers you want to bill. Pharmacy organizations now have to think about how to organize their workforce to get all their individual pharmacists into payer networks. It’s a completely different business model and an important consideration as you think about how to manage your clinical services business. 

2. Payer Enrollment Has Some Catching Up to Do

Most payers have a fairly straightforward process for provider enrollment. The issue for pharmacists? These processes are designed for a select group of providers, namely physicians, and therefore are far less straightforward for pharmacists who want to enroll. It’s common to get all the way through a provider enrollment form only to find at the end that there’s no checkbox for pharmacist as the provider type.

Can this be overcome? Yes. But it requires a lot of time and back and forth that pharmacists just don’t have. This problem should improve with time as the payer world catches up to the changes in the pharmacy industry. In the meantime, it’s important to understand that this part of the process will take some time and commitment.

3. How do You Match Eligible Patients with Contracted Providers?

Another factor is how to match patient eligibility with contracted providers. If you have a scheduling solution, do you have a way to ensure that you will have a contracted pharmacist available to provide the service? If not, you could end up in a situation where patients come into the pharmacy for a clinical service, only to discover the pharmacist who is contracted for their insurance isn’t available at that time.

4. Ongoing Workforce Management is a Challenge

How do you prevent pharmacists from slipping through cracks and providing services when their credentials have expired? Or know which pharmacists are credentialed with which payers for which services? How should pharmacists who float between locations be credentialed? This very quickly becomes a very complicated problem to manage. And if your pharmacists start providing services for which they are not actively credentialed, you will be writing off charges and missing out on that valuable clinical services revenue.

You Can Do It!

Understanding how credentialing for pharmacists can impact your business is key. While credentialing can be a complex process, the benefits of offering expanded clinical services far outweigh the challenges.

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