MythBusters! Credentialing and Contracting

by David Pope, PharmD, CDE, Chief Innovation Officer

Immunizations and Medication Therapy Management (MTM) are the most common clinical services in pharmacy, and many pharmacists have successfully performed these services for years. But with the role of pharmacists as providers continuing to expand, there are opportunities to go to the next level with revenue-generating services such as point-of-care testing, diabetes education, smoking cessation and oral contraceptive prescribing, among others.

The COVID-19 crisis has accelerated the role of pharmacists as providers. On April 8, HHS announced that all pharmacists could administer COVID-19 tests. Following this announcement on May 8th, CMS provided clear guidance on how pharmacies can be reimbursed by Medicare for COVID-19 tests. This is a landmark decision that empowers pharmacists to provide point of care testing and demonstrates a growing appreciation of the accessibility of community pharmacies and the value that pharmacists provide in the delivery of primary care services traditionally handled by physicians.

As the opportunity for pharmacists to expand into additional clinical services has grown, unfortunately so has misinformation. I’ve seen a number of concerning statements that suggest there’s an easy path for pharmacists to get contracted and credentialed with all payers at once. Unfortunately, this is simply not possible. This process to be properly credentialed and contracted takes time, and it must be done separately with each payer. But the good news is that payers are actively adding pharmacists to their network as providers, and the end result is well worth it.

Dispelling the myths around credentialing and contracting

In order to be reimbursed by a payer for clinical services, you typically have to go through the same credentialing and contracting process as a physician. During the process, payers validate your credentials to ensure you’re in good standing with state and federal laws, and meet quality performance standards to provide certain patient care services. They also determine whether your specialty type -such as a pharmacist or diabetes educator- is needed within their network for that particular geographic region.

Here we set the record straight on five common myths surrounding credentialing and contracting.

 

Myth #1: Credentialing and contracting is a quick and easy process.

Fact: Outside of applying to Medicare for COVID-19 testing or other services, the credentialing process requires patience, persistence and time. The application paperwork alone can take a few hours for each insurance company. You need to determine which payers are the best fit for your pharmacy and patient populations, and complete an application for each target payer.

Once the application is submitted, the credentialing process generally takes up to 90 – 120 days. During that time, the payer verifies the documentation submitted, assesses whether your credentials meet the minimum requirements to join their network and whether their network needs additional providers of your specialty type. The contracting phase may take another 30 – 60 days. Pharmacists who take an active role in the process by following up on their application status, communicating consistently and forging relationships with payers are the ones who are most likely to be successful.

 

Myth #2: The credentialing and contracting process can be handled by a central third party, such as a pharmacy services administrative organization (PSAO) or a services vendor.

Fact: PSAOs are not focused on medical-side contracts, which are required for clinical services. There is not a single, nationally standardized application that you can submit to be in-network for all payers. It’s true that most payers (outside of Washington state) require you to complete a national credentialing system called CAQH. However, you should also expect that different payers may have specific credential requirements and that you will be asked for documentation to verify those credentials as part of the process.

 

Myth #3: The contract is always between the payer and the pharmacy.

Fact: A number of medical-side contracts are actually between the pharmacist and the payer. While this can vary by payer, that means that contracts are generally registered in your name as a pharmacist. If you own multiple locations or are a larger organization, you’ll want multiple pharmacists to be enrolled in the same plan in order to provide adequate coverage throughout the week and to prevent the potential loss of an agreement if a pharmacist leaves the company.

 

Myth #4: If I apply, the payer will let me in.

Fact: It is true that Medicare will allow ‘any willing provider’ into their network as long as you’ve completed their requirements. For example, enrolling with Medicare for COVID-19 testing, including testing for flu and RSV when ruling out COVID-19, represents a fast and simplified pathway for enrollment.

For other insurances, pharmacists must prove they are an expert in the clinical service they are seeking to provide in order to become in-network with a payer just like a physician. Today, many pharmacists hold not only a PharmD but also complete postgraduate residencies, both of which signify their medical knowledge and experience necessary to serve patients. Beyond your pharmacy credentials, it is helpful to show evidence of voluntary credentials, such as certificate programs and board certifications, that show expertise in the clinical services you plan to provide.

In some geographic regions, insurance panels can be very selective or closed. If a panel is closed, you can appeal a denial by highlighting your key qualifications, experience and the need for the clinical service. For example, perhaps you are planning to offer a service that is in high demand or you are located in an underserved area and  it would be worthwhile to stress these points in the appeal process.

 

Myth #5: Getting paid for clinical services is just like getting paid for pharmacy claims.

Fact: The reimbursement process for medical claims is very different from traditional pharmacy claims. To begin with, medical claims must be submitted in a different format to the insurer and are not adjudicated directly to the payer in real-time through the pharmacy management system like prescription claims. This introduces a level of risk when it comes to reimbursement because it can be weeks before you know if the claim will be reimbursed. The best way to protect yourself is with a medical benefit management company that can provide you real-time feedback on any eligibility or missing information in the claim that may impact your reimbursement.

Worth the effort

Credentialing and contracting can be a complex process, which can make pharmacists hesitant to expand their clinical services. But doing the work to achieve contracted, in-network status with payers is worth the effort. Once you have completed the contracting and credentialing process with a payer, you’ll have the ability to serve your patients with the expertise you provide as a pharmacist while providing unmatched accessibility.

Pharmacists and pharmacy organizations who attain medical-side agreements realize its financial benefits, such as increased revenue and diversified revenue streams, without having to rely on third parties to bring you the opportunity. Amid the challenges of a changing industry, tapping into non-prescription sources of reimbursement will help your pharmacy grow and thrive.

For more information on this topic, check out the OmniSYS Training Center.

 

David Pope, PharmD, CDE Chief Innovation Officer

In his role as chief innovation officer, David Pope, PharmD, CDE, leads OmniSYS’s efforts to develop innovative solutions that support the evolving role of pharmacy in healthcare delivery. Dr. Pope is a nationally-recognized expert in medical informatics and clinical services in the pharmacy space, and has served as an advisor for the Center for Disease Control (CDC) as well as multiple Fortune 500 healthcare-related organizations.

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