Reimbursement for Pharmacy Services PDF

Reimbursement for Pharmacy Services Donald Klepser, Ph.D., M.B.A. 1  Objectives l Describe the types of services that pharmacists provide l Differentiate between the different types of pricing methodologies l Discuss how pharmacis...

Reimbursement for Pharmacy Services Donald Klepser, Ph.D., M.B.A. 1  Objectives l Describe the types of services that pharmacists provide l Differentiate between the different types of pricing methodologies l Discuss how pharmacists receive reimbursement from Medicare and other insurers l Describe some examples of pharmacists being reimbursed for their services 2  Obtaining Reimbursement for Pharmacy Services l One of the most challenging aspects of implementing pharmacy services – Patients may not realize the value – Pharmacists’ attitudes in requesting compensation for their knowledge and expertise l Difficult to establish an appropriate pricing methodology – Lack of recognition of pharmacists as providers by insurers 3  Continuum of Pharmacy Services Less Intensive More Intensive OBRA ‘90 Type Services Wellness Case Management DSM Specialized Services 4  Types of Services l OBRA ‘90 Type Services – What the heck does OBRA ’90 mean? – Maintaining proper patient records – Prospective DUR services – Patient counseling and education l Expected for all (Medicaid) patients with every prescription l Unfunded mandate? 5  Types of Services l Clinical/Lab Services l Disease State – Immunizations Management (DSM) – Point of Care Testing – Hypertension – Anticoagulation services – Diabetes – Monitoring services – CAD l BP – CHF l Lipids – Asthma l A1c 6  Types of Services l Wellness Services – Weight management services l Weight and body fat analysis – Smoking cessation services – Screening services l Osteoporosis screenings l Cardiovascular screenings (BP, Lipids, Pulse) l Diabetes screenings (Blood glucose) l Glaucoma Screenings l Skin care screenings 7  Types of Services l Case Management Services – Geriatric Assessment Clinics 8  Types of Services l Other types of services – Brown bags – Compounding – Nutracueticals/CAM consults and product selection – OTC consults – DME consults and product selection 9  Long Term Care and Inpatient Services l Many of the same services l Inpatient pharmacy – Cost center – May not be reimbursed directly l Long term care 10  Determining the Value of the Service l Pharmacists need to take into account: – Time needed to provide the service – What resources will be expended – What margin is needed to make the service profitable – What the demand is for the service – What competition is in the market – What are competitors charging 11  Establishing a Pricing Methodology l Fee-For-Service (FFS) – Traditional method of billing for health care – Charge a specific rate for a service l Based on time l Fee established for a specific intervention – Criticisms l Incentive to provide more care l Focuses on payment for actions, not on fulfilling patient needs 12  Establishing a Pricing Methodology l Fee-For-Service – Examples l Immunization/Vaccination = $25 for annual influenza vaccine l Health Care Financing Administration (HCFA) demonstration project conducted from 1992-1996 – Washington State Medicaid Program l Pharmacists paid $4.00 for patient interventions of less than six minutes l Pharmacists paid $6.00 for patient interventions of greater than six minutes l Pharmacy Check-up Program = $75 l Lipid panel with risk factor assessment = $45.00 13  Establishing a Pricing Methodology l Resource-Based, Relative-Value Scale (RBRVS) – Payment amount is directly related to the level of service provided – Used for payment of physician services – Medicare and other payers are just starting to recognize pharmacists as providers – Reimbursement sometimes occurs “incident to” physician care 14  Establishing a Pricing Methodology l RBRVS Example – Wellmark Blue Cross Blue Shield demonstration project in Iowa l Payment to pharmacists for cognitive services l Payments ranged from $14.00 to $105.00 per patient each quarter – Payments for patients with more complex cases who are taking multiple medications was at the higher end of the range – No payment if the patient was not seen during the quarter l Iowa PCM Benefit – Modified RBRVS/Capitation System – Payment ranges from $25.00 to $75.00 per visit 15  Establishing a Pricing Methodology l Capitation – Services provided for a fixed fee l Usually per patient, per month – May be appealing to the payer l Cost is predetermined and not dependent on utilization – Provider share the financial risk l Keep costs below the total monthly capitated amount – Criticism l Reduced patient access to services 16  Establishing a Pricing Methodology l Capitation Example – Disease State Management Programs l Diabetes – $400.00 per patient per year 17  Setting Fees l Basic Considerations – Determine the cost of doing business – Determine a reasonable profit – Factors to consider l Facility changes, training, licensing requirements l Pharmacist’s salary, benefits, clerical support, and overhead necessary to provide the services l Fees need to be set so that they will sustain the business practice – Consider competition and their fees 18  Setting Fees l General Rules – Individual providing service should generate two or three time their salary in revenue – If you can’t do it profitably, don’t provide the service – “No Margin, No Mission” 19  Develop a Billing Process l Super Service Pharmacy (SSP) Example – Developed a fee structure for each of their services (this may be by trial and error) l POC testing for influenza and GAS l Case management services l Medication review services l Wellness services l Medication/Disease state monitoring services l Immunizations 20  Develop a Billing Process l SSP Example – Patients are informed of the fees – Payment is collected before the services are rendered – Help patient submit appropriate documentation to their insurance carrier and submit appropriate forms – Forms used: Certificates of Medical Necessity, cover letter requesting payment, supporting documentation of services provided, invoices 21  Understanding Third Party Payers l Claim forms – Centers for Medicare & Medicaid Services 1500 claim form (Also called a master bill) l Used to bill medical services to an insurance program and is universally recognized and accepted for physician billing l ICD-9 codes (International Classification of Diseases) – Diagnosis codes used by payers to classify illnesses, injuries, and patient encounters with providers l Diabetes = 250.0 22  Understanding Third Party Payers l Claim Forms – CPT codes (Current Procedural Terminology) l Developed by the American Medical Association l Updated and published annually l Describe medical services and procedures performed by physicians and other health care providers 23  Understanding Third Party Payers l CPT Codes – Most common used by pharmacists: l 99201-99205 new outpatient l 99211-99215 established outpatient – Other codes that have been used: l Consultation codes: 99241-99245 l Confirmatory consultation codes: 99271-99275 l Case management codes: 99361, 99371-99373 l Preventive medicine codes: 99381-99397 l Lab codes: 82465, 80061 = Cholesterol, 83036 = A1c, G001 = finger stick 24  Understanding Third Party Payers l Other types of claim forms – The Pharmacist Care Claim Form (PCCF) l Developed by the National Community Pharmacists Association (NCPA) l Tool for documenting and billing for services l Attach to CMS 1500 – Outcomes™ Encounter Form l Three levels of service – Formulary management = $5.00 – Patient counseling with follow-up on an new medication = $7.00 – Problem identification and resolution = $15.00 l Estimated cost avoidance 25  Understanding Third Party Payers l Medicare Part B – Pharmacists are just now becoming recognized as providers l Could not get UPIN numbers l Must get the National Provider Identifier (NPI) l Should be beneficial – This is key because clinical services are not billed through PBMs. 26  Understanding Third Party Payers l Medicare Part B – Can bill “incident to” the physician l The service must be an integral part of a physician’s diagnosis or treatment l It should be provided under the direct supervision of a physician l It should be provided by an employee of a physician l The service should be done in a physician’s office or physician directed clinic 27  Understanding Third Party Payers l Medicare Part B – Can bill as a laboratory l For low complexity lab test (A1c, lipid panels, RDTs) l Need CLIA waiver l Cannot bill directly for counseling that accompanies the test 28  Understanding Third Party Payers l Services that are paid for by Medicare Part B – Anticoagulation clinics l CPT 99211 = cognitive services = $17.26 l CPT G001 = finger stick = $3.00 l CPT 85610 = Coagcheck = $5.49 – Lipid clinics l CPT 99211 ? l CPT G001 l CPT 80061 = full lipid panel = $18.72 29  Understanding Third Party Payers l Services that are paid for by Medicare Part B – Diabetes education l Need to be ADA recognized l Up to 10 hours of education as one time comprehensive education l Up to 2 hours annually l Individual ($30.00 per 30 minutes) or Group ($20.00 per 30 minutes per person) sessions – Diabetes management l CPT Code 83036 = A1c = $13.42 l CPT 99211 ? l CPT G001 30  Understanding Third Party Payers l Services that are paid for by Medicare Part B – Brown bag or Medication review l CPT code 99211 l ICD 9 codes = v65.49 = “other counseling” l Special Notes – Accepting assignment – Rural Health Clinics 31  Understanding Third Party Payers l Medicare Part D – The Holy Grail – Medication Therapy Management Services (MTMS) l Only MTMS l Each insurer allowed its own method for providing the service and not mandatory yet l Limited to certain patients 32  Understanding Third Party Payers l Other Insurers – Many follow Medicare rules – Most do not include pharmacists in their provider categories – Communication with other insurers l Identify appropriate person – Someone in medical claims, not pharmacy claims – Verify patient’s coverage, deductible, and co-payment l Ask for provider relations department to get essential information such as services that are covered, forms and coding systems preferred, confirmation about whether the pharmacy can accept assignment 33  Understanding Third Party Payers l Other insurers – Get the payer to agree in advance to cover the services before providing it – Provider number l Medicare Durable Equipment (DME) supplier l Alternate lab provider for Medicare l Seeking your own provider number with each insurer l New NPI 34  Understanding Third Party Payers l Other insurers – What if the claim is rejected? l Set up appointment with the payer’s case manager l If still rejected, speak with the clinical pharmacist from the medical benefits division l Be prepared to provide any documentation that they request l Indicate what the outcome could have been had the service or intervention not occurred l If still rejected – patient is responsible 35  Examples in Practice l Outcomes Pharmaceutical Health Care – Add on to health plan – Pharmacies join network – Contracts with l City of Ames l Cedar Rapids, IA school system l City of Davenport, IA 36  Cash Paying Customers l Don’t forget about the cash paying customers l Show them the value of the service and they will pay for them l The chiropractic example – Provide a service for which people are willing to pay cash – Patients will demand that insurer’s cover the service 37  Conclusions l Pharmacists have been successful in receiving reimbursement for their cognitive services l Obstacles still exist for pharmacists to receive reimbursement for their services l Pharmacists need to be prepared to provide services once their reimbursement has been defined 38