How Pharmacists Take Control of Medical Billing

Pharmacists are increasingly recognized as frontline health care providers, but many still are not paid for the clinical services they deliver. In an episode of Medical Billing Decoded, clinical pharmacist Jennifer Griffin, PharmD, and clinical program director Duane Jones, BSPharm, argue that the path to fair reimbursement runs through credentialing and contracting with medical payers.

Griffin, who leads medical billing protocol work for Harps Food Stores, frames credentialing as a mindset shift. Pharmacists already know their clinical value, she says, but health plans will not consistently pay for that value until pharmacists behave like other providers and participate in the same credentialing systems physicians accept as routine.

Jones, who oversees clinical programs and regional pharmacy operations for Harps Pharmacy, rejects the idea that credentialing is too burdensome. He calls it a one-time investment that compares favorably to the recurring demands of audits, which consume time but rarely deliver financial benefit. By contrast, time spent on credentialing can yield ongoing revenue for clinical services with only periodic updates required.

At Harps, a structured template allowed the team to credential 37 pharmacies and 80 pharmacists in just 30 days. For Jones, this proves that the barrier is more about priorities than complexity.

Both pharmacists warn, however, against outsourcing credentialing and billing to third-party companies that promise to handle everything. Jones cites cases in which pharmacies paid thousands of dollars without ever seeing a successfully paid claim and others where pharmacies faced liability after their national provider identifiers were used to submit questionable or even fraudulent charges. When something goes wrong, they stress that it is the pharmacy—not the vendor—that regulators hold responsible.

Instead, they urge pharmacists to own their data, build their own processes, and use tools like CAQH ProView to streamline credentialing. With physician shortages, expanding test-and-treat models, and potential federal action on programs like the Ensuring Community Access to Pharmacist Services Act, they argue that payers will increasingly look to credentialed pharmacists to fill critical gaps in care—and those who act now will be best positioned to benefit.

“Your returns in the future are going to be much greater through being a provider, getting credentialed, and being able to practice at the top of your education,” Jones said. “That's the most rewarding thing: to actually utilize the knowledge that you paid for in pharmacy school to be able to impact a positive outcome for a patient. That’s where we get our true gratification, and those opportunities are going to be immense in the future.”