Although pharmacists are using avenues available to bill under fee for service, there remains very few opportunities for pharmacist to directly bill a payer for their services. The majority of pharmacists have their services reimbursed through supervising providers using established patient codes or “incident to”, chronic care management codes or transition
A number of years ago when I began to try to figure out how pharmacists could get paid for patient care services I had the opportunity to hear a presentation from Krystalyn Weaver, PharmD, the Director of Policy and State Relations at NASPA (National Association of State Pharmacy Association). The question has essentially been her major focus at NASPA. She stated that three conditions must occur at the state level and they are as follows:
- Designation for pharmacists as health care provider in state law.
- Optimized scope of practice within the state pharmacy practice act
- Payment for services included within the State Insurance Code
The first requirement for payment is for pharmacists to be considered legal health care providers within the state. This is done through legislation that is passed into law. At least 38 states have code somewhere in their laws that designates pharmacists as health care providers. Ideally it is a statement in the practice act, however it may be in other types of legislation. For example, in Illinois, the pharmacy practice act states pharmacists are health care providers:
“Pharmacist” means an individual health care professional and provider….
Illinois also states pharmacists as health care providers in the Heroin & Opioid Overdose Prevention Act PA99-0480
Health Care Professional means…….. or a pharmacist licensed to practice pharmacy under the Pharmacy Practice Act
The second requirement is the pharmacy practice act in the state must include the patient care services that are to be billed. Statements describing pharmacy practice in the act should encompass the services such that a payer can determine the provided service is within the pharmacist’s scope of practice. The statements may be description of services authorized through the states’ collaborative practice agreement. The amount of variability in terminology, scope of practice and elements in both practice acts and the rules for collaborative practice agreements among the states is astonishing. Careful review of the specific state practice act and collaborative practice agreements is mandatory to ensure the services provided are within the pharmacist’s scope of practice as determined by state law.
The third requirement is the state insurance code for commercial health care payers, permitted to operate in the state, must require payment of pharmacists for the patients care services they provide within their scope of practice. Each state licenses commercial payers to operate in their state, they also set minimum benefits that the payers must provide the citizens of the state and set rules for operation including who should be paid. For example, the insurance code in Illinois states the following: “(e) Non-institutional provider – means any person licensed under the Medical Practice Act of 1987, as now or here after.” The insurance code in Illinois states only those licensed under the Medical Practice Act must be paid in a non-institutional setting. To date four states have changed state insurance code regulations through legislation to include payment of pharmacist patient care services. They are as follows:
- Washington: 2015 – SB 5557 – pharmacists as medical providers requiring compensation under major medical insurance for pharmacists providing health services contained in benefits
Tennessee: 2017 Pharmacy, Pharmacists - As enacted, expands to include pharmacists in the prohibition on discrimination by managed health insurance issuers against optometrists, ophthalmologists, podiatrists, and chiropractors solely on the basis of their license or certification……….. if such providers are acting within the scope of their license or certification. - Amends TCA Section 56-32-129
Ohio: 2019 Sec. 1751.91 . A health insuring corporation may provide payment or reimbursement to a pharmacist for providing a health care service to a patient if both of the following are the case : (A) The pharmacist provided the health care service to the patient in accordance with Chapter 4729. of the Revised Code, including any of the following services: (1) Managing drug therapy under a consult agreement with a physician pursuant to section 4729.39 of the Revised Code; (2) Administering immunizations in accordance with section 4729.41 of the Revised Code; (3) Administering drugs in accordance with section 4729.45 of the Revised Code. (B) The patient's individual or group health insuring corporation policy, contract, or agreement provides for payment or reimbursement of the service.
- Texas: 2019 Sec.A1451.128.AA SELECTION OF PHARMACIST. An insured may select a pharmacist to provide the services scheduled in the health insurance policy that are within the scope of the pharmacist ’s license to practice pharmacy under Subtitle J, Title 3, Occupations Code.