Travis Wolff, PharmD, BCACP, presents on the current landscape of medical billing in pharmacy practice and the steps pharmacists can take to realize a significantly higher profit margin.
From fee-for-service (FFS) to value-based payment models, pharmacists in all 50 states have a unique ability to bill directly for medical benefits. However, with each state providing a variety of avenues for medical billing, it’s up to pharmacists to explore their capabilities and execute on these financially.
“My mission is to make sure that you know what all is available to you as pharmacists and what resources are out there. There are more opportunities today than ever to do medical billing as a pharmacist,” Travis Wolff, PharmD, BCACP, CEO and director of pharmacist medical billing at PharmFurther, said in his presentation at the American Pharmacists Association’s Annual Meeting and Exposition 2026.1 “It really is going to be the future of where we're headed, and you really have to engage with those local, boots-on-the-ground concepts, because if you don't, you're going to get left behind.”
In a rapidly evolving health care landscape, American pharmacists are standing at a critical crossroads where traditional dispensing margins no longer sustain a viable practice. Experts argue that the future of the profession lies in medical billing—a transition that treats pharmacists not just as dispensers but as clinical providers entitled to significant revenue multipliers.
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Although many pharmacists feel the weight of administrative burdens, the potential for clinical revenue is immense, with some services offering a 5-to-9-fold increase in profit compared with the average gross dispensing margin of roughly 15 dollars.1
According to the American Society of Consultant Pharmacists, the federal government is already paving the way, with the Centers for Medicare and Medicaid Services (CMS) finalizing a 2026 physician fee schedule that expands billing opportunities by redefining “direct supervision” to include real-time telecommunications.2
These changes preserve COVID-era flexibilities and allow pharmacists to play a larger role in managing conditions like heart failure through mandatory ambulatory specialty models. Furthermore, CMS is encouraging pharmacist-led monitoring clinics for patients on antipsychotic medications, acknowledging that such collaborative care models can lower overall medical expenditures.
The technical transition requires a departure from the relatively simple, instantaneous world of pharmacy benefit manager claims based on national drug codes.3 Instead, medical billing utilizes a complex system of current procedural terminology and health care common procedure coding system codes that describe exactly what clinical service was provided.1,3,4
To navigate these waters, pharmacists must distinguish between hospital-based and physician-based billing models. In hospital-owned facilities, dual charges for professional and facility fees are common, though pharmacists often face barriers to independent billing in these settings.5 Conversely, physician-based settings may offer better positioning for pharmacists to generate revenue through state-specific or payer policies.
The industry is also pivoting toward value-based care, a model that rewards providers for the quality and effectiveness of their care rather than just the volume of visits. This transition creates deeper partnerships between pharmacists and patients, particularly in managing chronic conditions and closing gaps in care.5,6
Success in this new frontier requires proactive credentialing and engagement with clinically integrated networks to manage payer relationships. Pharmacists are encouraged to utilize resources such as pharmacy profiles to demonstrate their clinical qualifications to insurance carriers.1
In the first installment of the series, Jennifer Griffin, PharmD, MS, clinical pharmacist for Harps Food Stores, and Dwayne Jones, BSPharm, regional pharmacy supervisor and clinical program director for Harps Food Stores, share how a small regional chain successfully built and scaled clinical services across 39 pharmacy locations—without adding extra staff.
Although the learning curve for medical billing is steep and requires mastery of diagnosis codes and payer manuals, the accessibility of pharmacists remains their greatest asset. With 90% of Americans living near a pharmacy and public trust remaining high after the successful delivery of millions of COVID-19 vaccines, pharmacists are uniquely positioned to unlock sustainable revenue through direct patient care.1,3
The profession must embrace its clinical scope of license now rather than waiting for a federal provider status mandate that has been stalled in committees for years.1
“I always have said that we will stand together or fall alone. The big issue we have in pharmacy is we all want to be in our own organizations, and then we don't look out for each other, and then we fall,” concluded Wolff. “But we'll go into this together and make sure all of you know how to do medical billing, make sure all of you know to take care of your patients, document and get paid for it, and [it] will go a long way.”
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