The Case for Medical Insurance Contracting: Pharmacists are Poised to Close Gaps in Care
PART OF OUR UNDERSTANDING SERIES: Credentialing and Health Plan Enrollment for Pharmacists
By Preston Cranford CEO & Co-Founder, Provider CSAO
The pharmacy profession is undergoing a dramatic transformation. No longer confined to dispensing medications, pharmacists are emerging as accessible, highly skilled healthcare providers ready to meet the growing clinical needs of patients nationwide. As more states expand the scope of practice for pharmacists and more health systems feel the pinch of provider shortages, both government agencies and private medical insurance companies are beginning to recognize the value pharmacists bring to closing critical gaps in care.
According to data from the Health Resources & Services Administration, more than 100 million people in the United States live in health professional shortage areas. That means entire communities lack access to basic services like chronic disease management, preventive care, and patient education. Pharmacists—licensed, accessible in nearly every ZIP code, and trained in managing complex medication regimens—are ideally positioned to help fill these voids. In fact, pharmacists can now provide a wide range of reimbursable clinical services, including immunizations, point-of-care testing, MTM (medication therapy management), DSME (diabetes self-management education), smoking cessation counseling, and more.
As the role of pharmacists expands, so must the infrastructure that supports them. A critical piece of that puzzle is in-network participation with medical insurances. There are hundreds of private and public medical payers across the United States, from large national plans to regional HMOs, and each one has its own process for credentialing and contracting. Navigating these systems can be time-consuming and complex, but it’s absolutely essential for pharmacists who want to be reimbursed directly for the clinical services they provide. The first step in this journey is understanding the medical insurance landscape in your local market—identifying which plans cover the majority of patients in your area allows you to prioritize the payers that will have the most meaningful impact on your practice. We also encourage pharmacists to begin collecting and securely filing medical insurance cards as early as possible. This not only prepares them for future billing but also helps assess payer mix and demand, which informs credentialing and contracting decisions.
Before diving into payer contracting, pharmacists need to get their ducks in a row. This starts with general credentialing (verifying your professional qualifications and licenses) and then payer-specific credentialing, which typically includes background checks, documentation, and compliance checks. Once credentialing is complete, pharmacists can approach payers for contracting—but that process is about more than just signing a form.
A well-structured contract ensures that pharmacists are being reimbursed fairly and consistently for the full scope of clinical services they offer. It’s essential to review and negotiate reimbursement terms carefully, especially when adding services beyond immunizations—such as diabetes education or point-of-care testing—to your practice. One critical aspect that often causes confusion is making sure the contracting is completed correctly at both the Type 1 NPI (individual provider) and Type 2 NPI (facility or business) levels. Failure to properly contract at the right NPI level can lead to billing delays, claim denials, and long administrative headaches.
Pharmacists are ready to meet this challenge head-on. With clinical expertise, accessibility, and a growing toolbox of reimbursable services, they are well-positioned to step into provider roles that address unmet needs across the healthcare system. But taking full advantage of these opportunities requires more than clinical readiness — it demands administrative preparation and a clear strategy for navigating the medical insurance landscape. Credentialing, contracting, and billing are essential components of this transformation, and getting them right is critical to long-term sustainability. For those seeking support, Provider CSAO exists to help pharmacists by managing this process from start to finish, so they can focus on delivering care while we handle the behind-the-scenes infrastructure that makes it all possible.
In many ways, the medical side of pharmacy is now undergoing the same transition the prescription side experienced in the late 1980s and early 1990s. Back then, it was a fragmented and difficult process for independent pharmacies to get contracted with individual prescription drug plans, often requiring dozens of separate relationships. That all changed with the invention of the PSAO (Pharmacy Services Administrative Organization), which helped standardize and streamline those efforts, allowing pharmacies to focus on care instead of paperwork. Today, we’re seeing the same need on the medical side, and Provider CSAO (Clinical Services Administrative Organization) is stepping into that role—serving as the “PSAO for medical” to simplify, support, and accelerate pharmacists’ entry into clinical reimbursement.
The pharmacy profession is changing, and the future belongs to those willing to adapt. By contracting with medical payers and building a foundation for clinical services, pharmacists can lead the way in addressing healthcare gaps and creating more sustainable, patient-centered practices.
About Provider CSAO
Provider CSAO is a credentialing & contracting service for pharmacies (independent, hospital, clinic, and other). We work on behalf of our clients to contract and become in-network with medical benefit insurance payers and negotiate reimbursements on their behalf. We strive to help pharmacies expand in clinical services while being reimbursed as providers to better serve their communities and improve healthcare accessibility across America.
To learn more about how Provider CSAO helps Pharmacists secure medical insurance contracts or to meet with a team member, please see the Provider CSAO Website
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.
