Billing-340B-Gee-2023 PDF

Financials of Pharmacy: Financial Basics in Ambulatory Care Pharmacy and 340b Discount Program Jodie Gee, Pharm.D., BCACP, CDCES Clinical Assistant Professor Learning Objectives 1 Be able to define provider status in the profession of pharmacy and how it affects the business side of pharmacy 2...

Financials of Pharmacy: Financial Basics in Ambulatory Care Pharmacy and 340b Discount Program Jodie Gee, Pharm.D., BCACP, CDCES Clinical Assistant Professor Learning Objectives 1 Be able to define provider status in the profession of pharmacy and how it affects the business side of pharmacy 2 Recognize the different billing methods and when to use each billing method 3 Identify criteria and regulations for 340b discount drug pricing Lecture overview Provider Status Billing Methods in ambulatory care Potential Revenue Discount Program for medications: 340b Background • Ambulatory care clinic program development • Purpose • Background • Clinic Structure • Implications • Assessment • Billing • Financial Summary • Resources Justification for pharmacist jobs in the clinical setting Why is billing for pharmacy services important Potentially sustainable service model --> More growth financially --> More job opportunities Payment for time spent with patients Better clinical outcomes with clinical pharmacist involvement in the clinic setting Lecture overview Provider Status Billing Methods in ambulatory care Potential Revenue Discount Program for medications: 340b The Struggle is Real….. • So we know all of the benefits of billing for clinical pharmacy services…..Why aren’t there a lot of million dollar clinical pharmacy models out there???? • PROVIDER STATUS • Pharmacists not recognized as providers under the Social Security Act (Medicare part B) à Cannot be reimbursed for services by government entities • Challenges: • Belief that other providers (such as nurses or physician assistants) can do pharmacist jobs in clinic setting for a cheaper price • Pharmacists associated with a product (prescriptions)à Assumption is that clinical services are paid through profit margins of dispensing prescriptions Pharmacotherapy 2011; 31(1): 1-8 The Struggle is Real….. • Challenges (continued) • Opposition from MD groups (they think pharmacists will be practicing medicine)……BUT the truth is….. • Pharmacists would only practice in designated scope of practice • Pharmacists want to work with MDs, not replace • Evidence has shown better clinical outcomes and cost savings with a pharmacist on the care team • Pharmacists can triage patients and refer to MDs when a higher level of care is needed • Legislation is expensive (Congressional Budget Office assigned the cost that is considered too high to be worth it) https://www.pharmacytoday.org/action/showPdf?pii=S1042-0991%2821%2900178-X Provider status – On the Federal Level • Definition: Recognition of being a “provider” under the Social Security Act permits Medicare beneficiaries access to health care services, and subsequent reimbursement of those services by the health care provider. • Social Security Act (SSA) determines eligibility for health care programs such as Medicare part B (covers outpatient care, preventative services, durable medical equipment) • Examples of providers under Medicare part B of the Social Security Act: Physicians, podiatrists, physician assistants, nurse practitioners, psychologists, social workers, nurse midwives, certified nurse anesthetists, optometrists • Without provider status à Patients and other health care providers are blocked from accessing benefits achievable through clinical pharmacy services Pharmacotherapy 2011; 31(1): 1-8 Provider Status – Where are we? • Federal level: Pharmacists are not recognized as providers L • State level (Texas): Pharmacists are not recognized as providers L • Private level (Texas): YES! We ARE!! Regarding commercial/private health insurance plans • In 2019, TX Gov. Abbott signed HB 1757 into law allowing beneficiaries (patients) of commercial health plan to select a pharmacist as a provider to provide services in the health insurance policy • We are slowly inching our way up to a good place to get reimbursed fully So why is the struggle still real? Essentially, the breakthrough will be when pharmacists are providers at the federal level à Opens up the ”holy grail” of reimbursement from Medicare and Medicaid Current state of the matter • Currently, in Texas the reimbursement from commercial insurance payors is still very new à Law signed in 2019, but became effective January 1, 2020 • Establish pharmacists in the commercial insurance plan’s provider networks • Plans need to establish reimbursement amounts for pharmacy services • Clinics may need to negotiate specific contracts with the commercial insurance companies Current state of the matter • Currently, at the federal level • HR 5389 Medicare Clinical Pharmacist Practitioner Coverage act of 2010 à Referred to Subcommittee on Health of the House Ways and Means Committee • GROUND BREAKING: Affordable Care Act recognized pharmacists as providers in regards to medication therapy management (MTM) on a FEDERAL LEVEL • Medicare can reimburse pharmacists for MTM and immunizations So why is the struggle still real? • What can you do? • Follow and get involved: Texas Pharmacy Association (TPA), American Society of Health-System Pharmacists (ASHP), American Pharmacists Association (APhA), National Alliance of State Pharmacy Association • Write to your local state legislation • Follow healthcare reform https://www.govtrack.us/congress/bills/118/s2477/text S. 2477: Equitable Community Access to Pharmacist Services Act https://www.congress.gov/bill/118th-congress/senate-bill/1491/all-actions?overview=closed&s=1&r=60#tabs S.1491 - Pharmacy and Medically Underserved Areas Enhancement Act Key Websites for Advocacy • https://www.pharmacist.com/Advocacy/Issues/Medicare-ProviderStatus-Recognition • https://www.pharmacist.com/Advocacy/Issues/Provider-Status • https://www.govtrack.us/congress/bills/117/hr2759 https://www.govtrack.us/congress/bills/117/hr2759 Comments/Personal experiences Lecture overview Provider Status Billing Methods in ambulatory care Potential Revenue Discount Program for medications: 340b Billing in Ambulatory Care Overview Clinic (Private, Physician Based) Hospital-based clinic Community Pharmacy Miscellaneous Factors to consider in billing Billing for cognitive services There are different methods of billing How do you know how to use which billing method for your clinic/service? • Structure of the clinic • Financial ties of the clinic to a hospital system • Relationship to a dispensing pharmacy (ie. Is there dispensing pharmacy inside the clinic?) Pharmacists must obtain NPI (national provider ID) number Clinic (Private, Physician Based) Setting Billing method Private clinic, physician-based Example: Your local independently owned private physician practice “Incident to” billing Clinic (Private, Physician Based) • Billing method: ”Incident to” • Use billing code 99211 • Lowest level of billing, regardless of time and complexity of the patient L • Pharmacists not recognized by Medicare, so must bill under collaboration with physician • “Incident to” the supervising physician Clinic (Private, Physician Based) Criteria/Regulations for ”Incident to” Billing: 1.Patient must be first seen by physician 2.Physician must provide authorization for pharmacist to manage patient (ie. Documented referral) 3.Physician must continue to see patient (ie. Physician must see patient every 3rd visit) 4.Service must be performed in a provider’s office or clinic 5.Service must be medically appropriate to be given in a provider’s office or clinic 6.Pharmacist’s services must be within the pharmacist’s scope of practice as dictated by State law 7.Services must be in accordance to State law 8.Physician must be on the premises (not necessarily in the room) when services are performed 9.The clinic practice must have a contract/legal control over the pharmacist and his/her services and the pharmacist must represent an expense to the clinic (ie. Salary or exam room or equipment or staff support, etc) Clinic (Private, Physician Based) • Considerations: • ”Incident to” billing at the 99211 CPT code yields about $18-24 per patient encounter • It is not profitable for the patient to see both the physician and pharmacist on the same day • If CMS receives 2 bills (one for pharmacist visit and one for physician visit)à they will pay just 1 reimbursement at the lesser value • All pharmacist-patient encounters must be documented in the medical chart • Subjective, Objective, Assessment, Plan • Due to low level of reimbursement, this may not be the most profitable in terms of direct reimbursement Billing in Ambulatory Care Overview Clinic (Private, Physician Based) Hospital-based clinic Community Pharmacy Miscellaneous Hospital-based clinic Setting Billing method Billing method Clinic that is owned and operated by a hospital/hospital system Ie. Harris Health System Hospital Outpatient Prospective Payment System (HOPPS) àBilling includes a facility fee from hospital and a provider fee Transitional Care Management Hospital-based clinic - HOPPS • Criteria/Regulations for HOPPS Billing: • Clinic must be financially tied to the hospital • Clinic tax identification number (TIN) is the same as the hospital • • • • Billing codes are grouped into ambulatory payment classifications (APCs) Use APC billing code 5012 A separate facility fee is generated with the bill, along with the provider fee Pharmacists not Medicare providersà Only facility fee will be paid by Medicare Hospital-based clinic- HOPPS Criteria/Regulations for HOPPS Billing (same as Private, Physician based clinic): 1. Patient must be first seen by physician 2. Physician must provide authorization for pharmacist to manage patient (ie. Documented referral) 3. Physician must continue to see patient (ie. Physician must see patient every 3rd visit) 4. Service must be performed in a provider’s office or clinic 5. Service must be medically appropriate to be given in a provider’s office or clinic 6. Pharmacist’s services must be within the pharmacist’s scope of practice as dictated by State law 7. Services must be in accordance to State law 8. Physician must be on the premises (not necessarily in the room) when services are performed 9. The clinic practice must have a contract/legal control over the pharmacist and his/her services and the pharmacist must represent an expense to the clinic (ie. Salary or exam room or equipment or staff support, etc) Hospital-based clinic - HOPPS • Considerations: • Using APC code 5012 (facility fee reimbursement) may yield ~ $99 per patient encounter • Pharmacist-patient encounters must be documented in the medical chart • Subjective, Objective, Assessment, Plan • Buy-in at the institution level/administration level may be difficult as well as the process with the financial department • If successful at implementation à This method would offset pharmacist salary depending on the payor mix Hospital-based clinic- Transitional Care Management • Transitional care management • New Medicare program as a part of the Affordable Care Act • Physician and “qualified non-physician providers” (including pharmacists) • Care management following discharge from inpatient hospital setting, observation setting, or skilled nursing facility • Claim must be submitted under Medicare recognized provider (physician) • Pharmacists may not bill, but they can contribute to the service Hospital-based clinic- Transitional Care Management • Transitional care management criteria: Established patient at the clinic Contact with patient/caregiver within 2 business days of discharge (phone) In-clinic visit within 7 or 14 calendar days Pharmacist must provide services in collaboration with a licensed Medicare provider (supervising physician) • Pharmacist can perform either telephone or face-to-face services such as medication reconciliation • Models: • • • • • Joint in-clinic visits with pharmacist and physician • Post-discharge follow-up calls to address medication related issues • Claim submitted ”incident to” the supervising physician • Face to face visit within 7 days discharge yields ~ $234 (keep in mind high $$ due to physician contribution) • Face to face visit within 14 days discharge yields ~ $166 Medicare Annual Wellness Visits (AWV) • Can be performed in a physician-based clinic or a hospital-based clinic • Annual wellness visits established under Affordable Care Act for Medicare beneficiaries • Prior to AWV, Initial Preventative Physical Examination (IPPE) must be completed by a physician or qualified non-physician practitioner (NOT a pharmacist) • Pharmacists may bill for AWV • Services are “incident to” the supervising physician so “incident to” rules apply Medicare Annual Wellness Visits (AWV) Components of AWV (A few are below) Considerations: Clearly outlined by Medicare (more info at www.cms.gov) Health risk assessment (ie. Psychosocial risks, behavioral risks, ADLs) AWV yields about $118/per patient encounter Review family and medical history Update list current medical providers Beneficial and possibly profitable in a primarily Medicare payor mix Medication review However, only 1 AWV per patient per year Obtain vital signs Immunizations update https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AWV_Chart_ICN905706.pdf Value-Based Care • Indirect payment • Reducing cost, improve quality of care • Meeting clinic quality measures through improvement of clinical outcomes • • • • Collaborative drug therapy management/chronic disease state management Telephone follow-ups between provider visits Pharmacy and therapeutics committee involvement/formulary Transitions of care Case Example 1 • Jennifer, an ambulatory care trained pharmacist wants to start up new ambulatory care clinical pharmacy services at a clinic • She has an opportunity to start services at a Smith Clinic that is owned by Harris Health System, and they share a Tax Identification Number (TIN) • The CEO of Harris Health System wants information from her regarding if and how she is going to bill for her services to justify her position • What are your suggestions? Case Example 2 • John is a clinical pharmacist who is hired to start clinical services at a small private practice physician-based clinic. He will be on faculty at Drug Dealer College of Pharmacy as an ambulatory care professor, and will staff the clinic 2-3 days of the week. His salary will be fully paid by the college. • His financially motivated clinic manager (Elliott) wants to review all clinical services and essentially “make money” out of everything. He approaches John (who has no clue about billing), and tells him that he needs to find a way to make the clinic money (even though his salary is fully paid by the college). The manager wants an outline of a proposal in 2 weeks. • John comes to you (the pharmacy billing expert) and desperately needs help. He is clueless about billing methods, billing codes, and reimbursement. • He wants to know if he can make the $500,000/year that Elliott wants out of his clinical pharmacy service. Case Example 3 • A private physician-based practice wants to hire a clinical pharmacist to help them manage diabetes, hypertension, and hyperlipidemia. They want the clinical pharmacist to staff a new satellite clinic 5 days/week where they will have a part-time physician on site 2 days/week. They are willing to pay the pharmacist a salary. • Stipulations from the Practice Owner • Clinical pharmacist will have to be by themselves in clinic 3 days/week (no MD on duty on site) • Clinical pharmacist will need to take patients for diabetes, hypertension, and hyperlipidemia if they call to make an appointment because the doctor just told the patient to go see them by word of mouth. • What billing method would we use in this clinical practice site? • What are your thoughts regarding the stipulations? Billing in Ambulatory Care Overview Clinic (Private, Physician Based) Hospital-based clinic Community Pharmacy Miscellaneous Community Pharmacy Setting Community Pharmacy Billing method Medication Therapy Management (MTM) Community Pharmacy • Medication therapy management • Paid for by Medicare Part D plans • Certain Part D plans contract with community pharmacies to provide MTM services to their patients • Community pharmacists or pharmacies may secure contracts with private insurance companies • Cannot be performed in a physician or hospital based clinic without a dispensing pharmacy on site • Billing codes (99605, 99606, 99607)à each code is additional 15 minutes • Face to face or telephone visits, depending on Part D plan Community Pharmacy • Real world examples of MTM • Outcomes MTM • Mirixa Pro • AspenRX à New application based https://aspenrxhealth.com Community Pharmacy • Considerations: • Reimbursement is determined by the third party payer (Part D insurance company) • Unfortunately, payment return on billing is on average ~ 30%, may be more • Workflow adjustment in a community pharmacy (especially regarding face-to-face encounters) • Tracking payments – where is the money going and who is going to keep track of this in a community pharmacy Miscellaneous – Diabetes self-management training/education (DSMT/E) • Program must be recognized by ADA or AADE and pharmacist is a Certified Diabetes Care and Education Specialist (CDCES) • Program must offer group classes as well as individual sessions • Medicare covers 10 hours of education the first year and 2 hours each subsequent year • 1 hour can be provided as individual session, the other 9 or 1 is group session • Comprehensive self-management education: Nutrition, physical activity, maintaining glycemic control, self management such as checking blood sugars and insulin administration • Individual session of 30 minutes yields about $56/patient encounter • Group session of 30 minutes yields about $15/patient Documentation Must have physician referral Must address medical condition Assessment of medical condition and plan within the scope of the pharmacist’s practice Must be signed by the pharmacist performing the visit When the physician is involved in the visit, his or her contribution must be documented All documentation should support level of care provided Barriers to Billing – In General • Lack of provider status • Lack of understanding by third party payers of the pharmacist’s role in patient care • Lack of appropriate and fair billing codes to accurately reflect the pharmacist’s time and work during a patient encounter • Complicated method to implement billing and the different requirements for the different methods Lecture overview Provider Status Billing Methods in ambulatory care Potential Revenue Discount Program for medications: 340b Potential Revenue: Important Items to Consider Physician buyin/supervision Health care system buy-in Payor mix: Medicare, Medicaid, Private/commercial insurance, uninsured Potential clinic volume Sustainability Working with clinic/health system financial department when starting services Financial metrics to track Lecture overview Provider Status Billing Methods in ambulatory care Potential Revenue Discount Program for medications: 340b How many of you (or someone you know) have been affected by high drug costs? 340b Program Overview • Federal program allowing certain covered entities (hospitals) to purchase medications at discounted prices from drug manufacturer to provide to patients at subsequently discounted prices • Hospitals can use that cost savings to provide more comprehensive services • Background • U.S. Congress created 340b program to protect certain hospitals from rising drug costs • Limited drug manufacturers to amount they can charge covered entities for medications --> “Ceiling price” • Administered by Health Resources Services Administration “Covered entities” 340b Program Eligibility • Disproportionate share hospitals • Children’s hospitals • Cancer hospitals • Rural hospitals • HIV and Tuberculosis clinics • Federally qualified health centers (FQHCs) Covered entities meeting requirements must apply and register at hrsa.gov Benefits low-income patients/families and vulnerable populations 340b Program – Patient eligibility Outpatient medications Covered entity must have established relationship with patient (ie. Has health records of patient) Patient receives health care from a health care professional employed by covered entity or has contract with covered entity Average savings 25-60% for covered medications (sometimes more) 340b Program Models Traditional Model • Hospital purchases discounted drug from drug manufacturer usually through drug wholesaler/distributor and dispenses the drug at a discounted price at the hospital pharmacy Contract Model • Hospital has a contract with an outside pharmacy (aka Contract pharmacy) • Drug manufacturer discounts price of drugs and hospital has drug delivered to contact pharmacy • Patient picks up Rx from contract pharmacy • Pharmacy will bill patient’s insurance if they have it à keep a portion for dispensing fee and send the remainder back to hospital • Hospital makes a profit to provide more services or help provide medications to patients without insurance • Detailed receiving and dispensing records must be kept https://www.kff.org/wpcontent/uploads/sites/2/2014/06/215_8th_an nual_oncology_economics_summit__a_vandervelde_presentation.pdf https://www.kff.org/wpcontent/uploads/sites/2/2014/06/215_8th_an nual_oncology_economics_summit__a_vandervelde_presentation.pdf Use of 340b Savings by Covered Entities • Policy and procedure must state use of the savings to benefit the patients • Drug discount cards • Sliding scale clinic fees for clinic visits • Expanding programs or operations 340b Regulatory Areas Up to date registration of covered entity Diversion – 340b drug dispense to patient that does not meet the “patient” definition “Double dipping” – Duplicate discounting – Cannot bill Medicaid for 340b discounted drugs 340b Compliance Covered entity and pharmacy are subject to regular audits Must comply with all Federal and State laws Covered entities must recertify every year Financials of Pharmacy: Financial Basics in Ambulatory Care Pharmacy and 340b Discount Program Financials of Pharmacy: Financial Basics in Ambulatory Care Pharmacy and 340b Discount Program Jodie Gee, Pharm.D., BCACP, CDCES Clinical Assistant Professor