End-to-End Process for Pharmacist Engagement in Patient Care Services
PART OF OUR UNDERSTANDING SERIES: Credentialing and Health Plan Enrollment for Pharmacists
By Mark Pilkington, BS, MS, Executive Director, Pharmacy Profiles
As pharmacy practice transitions from a product to patient care focus, pharmacists will be challenged to understand how to engage the health care system differently. For decades, pharmacists have focused on the pharmacy benefit to process prescription claims. Now, pharmacists providing patient care services must understand and engage in a patient’s medical benefit. Recognition as a health care provider requires pharmacists to engage health plans much like any other provider. Enrollment as a provider, contracting, documenting, and billing for services is very different in the medical benefit environment. Pharmacists can become frustrated and discouraged in the process of engaging the medical benefit.
To assist pharmacists’ understanding of “How Pharmacists Engage the Medical Benefit”, Pharmacy Profiles has produced a short How it works video that describes each step in the process. Additionally, over the coming months, each step in the engagement process will be addressed by subject matter experts. Short articles are offered on each topic. The intention of this work is to enhance pharmacists’ understanding and engagement in the medical model.
The Past
Community pharmacists are experts at processing prescription drug claims through Pharmacy Benefit Managers (PBMs). A new prescription enters the pharmacy, the pharmacist matches a drug product file to the patient’s pharmacy benefit profile within the pharmacy’s Pharmacy Management System (PMS) and pushes a button. Much like a bank processes an ATM transaction, within seconds the prescription drug claim is processed and returns a response to the pharmacy. Data related to the patient’s drug benefit coverage, copay requirements, and total payment is communicated to the pharmacy in near real-time.
Prescription claims are paid to the pharmacy consistent with NCPDP claims transaction standards. Pharmacies are enrolled in payer provider networks and are credentialed and contracted with PBMs. Pharmacists are generally not identified in the prescription drug claim process.
The Future
Community pharmacies are now health care destinations. Patients look to pharmacists practicing in community pharmacies for health care services like medication management, immunizations, and point-of-care testing. Pharmacists practicing in community pharmacies have obtained appropriate training and competency certification to deliver care demanded by patients in their neighborhood.
Billing for pharmacist-provided patient care services in community pharmacy is a completely new process for pharmacists. Claims for patient care services are submitted to a patient’s medical benefit, not the pharmacy benefit. Medical benefit claim submission requires pharmacists to enroll with each health plan as health care providers, contract to provide services, document patient care, invoice the payer, and then manage account receivable.
Pharmacist Health Plan Enrollment
The process for health care providers to enroll with a health plan, also known as provider enrollment or payer enrollment, typically involves multiple steps.
- Step 1 of the health plan enrollment process is to identify a health plan in your market that allows pharmacists to enroll in their provider network. Care should be exercised to identify health plans will sufficient patient membership in your market area to make participation in that health plan’s provider network. In this step, once you’ve identified a health plan in your market area with sufficient members, go to their website to discover the enrollment process.
- Step 2 of the enrollment process is to complete the health plan’s application process. Each health plan or health insurance company may have a slightly different application process. However, most payers will require the pharmacist to provide their practice credentials – licensure, sanctions, training, etc. – during the application process. Some payers verify pharmacist provided credentials internally and some require pharmacists to provide credentials through an external Credentials Verification Organization (CVO). Examples of CVOs are CAQH and Pharmacy Profiles.
- During Step 3 of the health plan provider network enrollment, the health plan network staff reviews the pharmacist application for completeness and may cross-reference it with credentialing data to make sure the provider meets their requirements. If the application is complete, the health plan network team move to the final step (Step 4) in the enrollment process and submits the application to the health plan’s credentialing committee to review the pharmacist’s credentials and approve them if they meet their requirements.
Network Services
Before a pharmacist can provide services to patients who are members of health plans, pharmacists must be enrolled in the health plan’s provider network as described previously. Once enrolled, pharmacists must have a contract with each health plan to define terms and conditions of the services; requirements for documenting care; define service billing parameters; and understand payment terms.
In the medical benefits billing environment, contracting is typically at the facility level. For instance, a health plan rarely contracts with individual physicians but contracts with the clinics where the physician is employed. So, it is likely that health plans will endeavor to contract with a pharmacy or group of pharmacies versus individual pharmacists. Pharmacists enrolled with health plans will likely be part of a pharmacy network, like a chain pharmacy company or a Pharmacy Services Administrative Organization (PSAO).
Each health plan will have some level of required patient care documentation. So, a pharmacist will want to be working in an environment that has a robust patient encounter documentation system. Such an encounter system may include both a clinical data capture capability and a method of billing for a medical claim. Network services that include encounter documentation, medical claim submission, and accounts receivable may be part of the current PMS technology or may need to be freestanding technology.
Conclusion
The pharmacy profession is at the cusp of an exciting transition to a patient-centered practice. Understanding the end-to-end process of engagement in medical benefit claims submission is imperative. Pharmacists begin by enrolling as health care providers with health plans, health insurance companies, and Medicaid agencies. While the enrollment process with each payer will be unique, enrollment is the first step. Once enrolled, pharmacist network services will provide the underpinning for billing the medical benefit.
About Pharmacy Profiles:
Pharmacy Profiles, LLC, a wholly owned subsidiary of the American Pharmacists Association, facilitates the pharmacy personnel credentials marketplace. Pharmacy Profiles is a pharmacy personnel Credentials Verification Organization that collects, maintains, and verifies credentials data for pharmacists. As health plans seek to address access to care challenges for members, Pharmacy Profiles facilitates pharmacist enrollment in provider networks. With a focus on accuracy, timeliness, and reliability, the organization serves practicing pharmacists, pharmacy networks, and health plans by providing verified pharmacist credentials.
For more information about Pharmacy Profiles and its credentialing services, please visit www.pharmacyprofiles.com or contact Mark Pilkington, Executive Director, mpilkington@pharmacyprofiles.com, 202-429-7550.
