Best Practices for Pharmacy Billing, Payment, and Reimbursement

Change must start in the practice before payment can be delivered.

How can pharmacists best navigate billing and be compensated for the patient care they provide?

At her presentation at the APhA 2022 Annual Meeting & Exposition in San Antonio, Texas, Melissa Somma McGivney, PharmD, FCCP, FAPhA, professor and associate dean for community partnerships at the University of Pittsburgh School of Pharmacy, set out to explain just that.

“I’m going to take you on a bit of a journey when it comes to answering this question about how pharmacists can be billing and be compensated for patient care services,” she said, explaining that the 3 parts of the session would cover 4 key practice enhancements that are necessary to be able to support pharmacists patient care services and being able to bill for those services.

During the pandemic, McGivney explained, there was an incredible light shone on community pharmacies in ways that often the public didn’t recognize before.
“We have 65,000 community pharmacy doors in the United States, much more than hospitals, and we didn’t shut the doors or move entirely to technology during the point in time where everyone had to stay home,” she said. “So, we’ve started to get the attention of health payers, we’ve got the attention of physician groups, and we’ve also gotten the attention of the public. Access is what it’s all about."

Still, from the pharmacy side—because drug reimbursement as an all-time low—pharmacists need to be doing something different.

McGivney noted that although her tips are aimed at community pharmacy practices, but these principles can apply to any other pharmacist practice.

“We can’t talk about payment or change without acknowledging that there are challenges,” she said, pointing to current pharmacy workflows and volume. “The first point is really that practice change must start before payment. We can’t do anything before workflow changes.”

McGivney also discussed medication synchronization and appointment-based models as a way for pharmacists can review all of a patient’s prescriptions, adding that 80% of chronic diseases are managed by prescription medications.

“It allows us, from a staffing perspective, to calm down,” she said. “People do their best work when they feel valued and can focus. And so, what happens in a pharmacy is it’s really fast, because everything’s built on volume. When you flip over to synchronizing the meds and anticipating at least once a month, when folks are coming in, things calm down, and there’s some predictable work. That changes the way that people are able to do their work. It creates a planned workflow. It also improves pharmacy revenue because you’re actually getting folks to come in every single month.” That scheduling can be leveraged for other patient care services.

From the practice management side, McGivney noted that pharmacies should have access to technology that supports the work the pharmacist is doing, including strong electronic communication. Contracting for patient care services is also important and becomes more attainable when pharmacists and pharmacies are a part of a representative group, which can be done through an integrated legal infrastructure. Pharmacies in the network can share ideas, comment on what works and doesn’t, and help each other with a practice transformation.

McGivney concluded her talk by recapping the 6 important actions that must happen to improve billing going forward: Pharmacists workflow must change before payment; contracts must be in place before payment; contracting is absolutely possible and with a variety of different entities and is happening; contracting becomes more attainable with pharmacists and pharmacies when they’re part of a representative group or as recognized providers; contracting often begins locally; and payment models are widely variable.

Reference

McGivney MS. All things money: Pharmacy payment, billing, and reimbursement. Presented at: American Pharmacists Association 2022 Annual Meeting & Exposition; March 18-21, 2022; San Antonio, TX