Credentialed Pharmacists, Cash-Pay Services Drive the Adoption of Medical Billing

Pharmacies that offer cash-pay services and employ credentialed pharmacists were most likely to establish services billable under medical claims, according to a study in the Journal of the American Pharmacists Association.¹ As community pharmacies develop the proper workflows and administrative infrastructure, they are primed to provide a more robust offering of clinical and billable services.

“Pharmacists are increasingly providing patient care services in a variety of settings spanning inpatient, outpatient/ambulatory clinics, and community pharmacies,” according to NCPDP.² “Community pharmacists are continuing to provide services distinct from the traditional prescription dispensing function, offering patient care services such as immunizations, point-of-care (POC) testing, medication therapy management (MTM), chronic care management, transitions of care management, patient education, and counseling.”

Researchers in Arkansas found that despite educational interventions, like medical billing bootcamps, on-site visits, and continuing education, being widely available, they did not show a statistically significant correlation with a pharmacy's likelihood to submit medical claims. Instead, the strongest predictors of success were pharmacies that already offered cash-pay clinical services and employed pharmacists who had navigated the credentialing process.¹

This suggests a staged approach to practice transformation where establishing clinical workflows and administrative readiness through direct patient payment serves as a crucial precursor to navigating the complexities of third-party reimbursement.

READ MORE: Strategies to Drive Pharmacy Sustainability in a Changing Landscape

The Arkansas study revealed that nearly half of the pharmacies providing protocol-based services, such as influenza, Group A streptococcus, and COVID-19 test-and-treat, successfully submitted medical claims to Arkansas Blue Cross and Blue Shield within the first year of the opportunity. This milestone highlights the potential for community pharmacies to function as medical providers when the payer environment aligns with state protocols that authorize prescribing for common ailments.¹

The Importance of Contracting and Credentialing

However, the transition requires more than just clinical knowledge and necessitates a foundational understanding of the distinction between credentialing and contracting.^3,4

Credentialing is the essential verification process where a payer confirms a pharmacist's qualifications, licensure, and professional background to ensure they meet standards for patient care. Contracting follows this verification, establishing the formal financial agreement regarding reimbursement rates and the specific scope of work.⁴

Without proper credentialing, pharmacies face immediate financial risks, including claim denials and delayed payments that can lead to significant financial strain. Experts at Harps Food Stores emphasize that pharmacists must treat credentialing as a routine part of being a provider, adopting a mindset shift to behave like the physicians and other practitioners they collaborate with.^4,5

The mechanisms for reimbursement are varied and often depend on the specific practice setting and the benefit package providing coverage. Although the NCPDP Telecommunication Standard is a preferred and cost-effective billing format for many pharmacy-based services, medical plans often require additional formats for professional services.²

The Pathway to More Billable Services in Community Pharmacy

Beyond the traditional retail encounter, pharmacists are increasingly contributing to more complex medical services like chronic care management and remote patient monitoring (RPM). Although pharmacists currently cannot bill Medicare directly for many of these services, they can contribute to billable time under the “incident to” physician billing model, provided they are practicing under the appropriate level of physician supervision.^2,6

For example, in the management of chronic conditions like type 2 diabetes, pharmacists can play a vital role in utilizing continuous glucose monitoring to optimize pharmacotherapy. This data-driven approach not only improves patient outcomes but also provides a pathway for sustainable reimbursement when linked with collaborative practice agreements.⁶

Despite these emerging opportunities, a gap remains between the legal authority to bill and the actual submission of claims by many practitioners. National leaders emphasize that the profession must lean into these opportunities, utilizing tools like the Council for Affordable Quality Healthcare and Pharmacy Profiles to streamline the administrative burden.^3,5

The shift toward medical billing is a long-term investment in the profession’s future and professional growth. Pharmacists are cautioned against outsourcing these critical functions to third-party vendors, as the ultimate liability for data accuracy and potential fraud remains with the pharmacy rather than the vendor.^4,5

By owning their data and building internal documentation processes that match those used in broader medical practices, pharmacists can better demonstrate their value to the interdisciplinary health care team. As the health care system continues to face provider shortages, credentialed pharmacists who have mastered the nuances of medical billing are uniquely positioned to fill critical care gaps and ensure the financial viability of their clinical practices.^2,3,5,6

“Pharmacies already offering cash-based services or employing credentialed pharmacists were more likely to bill medically, suggesting implementation progresses as workflows mature,” concluded the authors of the current study.¹ “Ongoing evaluation of service delivery and billing practices will be essential to sustainable integration of pharmacist-provided clinical services.”

READ MORE: Pharmacists Can Shift to Provider Status With Medical Billing

REFERENCES

1. Smith MG, Moore L. Impact of medical billing education support on billing practices in Arkansas community pharmacies. JAPhA. 2026;66(5):103113. doi:10.1016/j.japh.2026.103113

2. Billing guidance for pharmacists’ professional and patient care services. NCPDP. June 2018. Accessed July 22, 2026. https://www.ncpdp.org/NCPDP/media/pdf/WhitePaper/Billing-Guidance-for-Pharmacists-Professional-and-Patient-Care-Services-White-Paper.pdf

3. Pharmacists: We must accelerate billing for services. News Release. American Pharmacists Association. September 3, 2024. Accessed July 22, 2026. https://www.pharmacist.com/APhA-Press-Releases/pharmacists-we-must-accelerate-billing-for-services

4. Credentialing success: how pharmacists can streamline the insurance verification process. DocStation. March 17, 2025. Accessed July 22, 2026. https://docstation.co/blog/credentialing-success

5. Gallagher A, Jones D, Griffin J. How pharmacists take control of medical billing. Drug Topics. July 17, 2026. Accessed July 22, 2026. https://www.drugtopics.com/view/how-pharmacists-take-control-of-medical-billing

6. Pierce KN, White L, Keedy CA. Utilizing pharmacists for billable services related to disease state management. JAPhA Pract Innov. 2023;1(1):100006. doi:10.1016/j.japhpi.2023.100006