Billing for Pharmacist Services as Part of a Health System
PART OF OUR UNDERSTANDING SERIES: Credentialing and Health Plan Enrollment for Pharmacists
By Daniel S Longyhore, Pharm.D., Ed.D., FCCP, BCACP, System Director of Knowledge Management, Enterprise Pharmacy, Geisinger
As health systems evolve, so do the roles of pharmacists within them. Initially, pharmacists in health systems were primarily hospital-based, providing medication-related services to hospitalized patients in need of acute care. Over time, as the healthcare system became more complex, the role of pharmacists expanded. Today, pharmacists continue to practice in hospitals, reviewing orders, preparing sterile products, consulting with patient care teams, and managing medications such as antimicrobials, anticoagulants, and blood glucose levels.
In modern healthcare systems, pharmacists also take on roles in primary care and specialty physician practices as advanced practice providers and extenders of the healthcare system. They work in clinics under collaborative drug therapy management agreements with physicians, manage home infusion services, community and retail pharmacies, mail-order pharmacy services, ambulatory infusion centers, and oral chemotherapy for patients. These roles have become crucial in addressing physician and advanced practice provider shortages, ensuring that patient care needs are met.
Recognizing the importance of pharmacists, payors across the US, particularly state Medicaid services, have started to acknowledge pharmacists as providers, allowing them to bill and be reimbursed for their cognitive services. This recognition is a significant achievement for the profession. However, navigating the process to become credentialed providers with a health plan can be challenging. Even in health systems where credentialing of clinicians is common, adding pharmacists to the list of credentialed professionals often raises questions and uncertainties.
Credentialing verifies a pharmacist’s training, licensure, and liability coverage, ensuring that they meet the necessary qualifications to provide safe and effective care. Without credentialing, health plans will not reimburse individual providers. The credentialing process can take several routes, some more complex than others. For pharmacists in a health system, the easiest route is for the health system’s Credentialing Committee to review their materials and provide information to the health plan, confirming that the pharmacist meets the qualifications to be a recognized provider. Typically, this information is provided by the health system as a delegate. However, credentialing pharmacists requires time and resources, which may not be accounted for in the system’s current infrastructure.
In such cases, pharmacists may need to explore alternative pathways to enroll and credential with health plans. These pathways often involve third-party organizations recognized by the National Committee for Quality Assurance (NCQA), such as the Council for Affordable Quality Healthcare (CAQH) or Pharmacy Profiles. These third-party organizations serve as repositories for providers to store their professional information, allowing health plans to access the details needed for credentialing. Providers using resources like CAQH or Pharmacy Profiles must review their profiles every 90 days to attest that the information is still correct. Health systems should implement oversight plans to ensure that their team members maintain all requirements.
While this process may be more time-intensive for pharmacists in health systems, it is a necessary step until health systems can allocate budgets and resources to expand their Credentialing teams to include pharmacists. As more payors, including Medicare and private insurers, recognize and reimburse pharmacists for their cognitive services, the incentive to expand Credentialing teams will grow, eventually integrating pharmacists into the traditional provider credentialing process within health systems.
About Geisinger
Geisinger is among the nation’s leading providers of value-based care, serving 1.2 million people in urban and rural communities across Pennsylvania. Founded in 1915 by philanthropist Abigail Geisinger, the non-profit system generates $10 billion in annual revenues across 134 care sites – including 10 hospital campuses, and Geisinger Health Plan, with 600,000 members in commercial and government plans. The Geisinger College of Health Sciences educates more than 5,000 medical professionals annually and conducts more than 1,400 clinical research studies. With 26,000 employees, including 1,600 employed physicians, Geisinger is among Pennsylvania’s largest employers with an estimated economic impact of $14 billion to the state’s economy. On March 31, 2024, Geisinger became the first member of Risant Health, a new nonprofit charitable organization created to expand and accelerate value-based care across the country. Learn more at geisinger.org or connect with us on Facebook, Instagram, LinkedIn and X.
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.
