Pharmacists’ reimbursement for cognitive services? It’s beginning
Payment could be as simple as semantics, positioning
As pharmacists take on prominent roles in disease management and patient counseling, can reimbursement for cognitive services be far behind? Recent changes in Medicare policies and legislation passed or pending in nine states have opened the door to more reimbursement for intellectual activities associated with patient care. These changes suggest several strategies pharmacists in all health care settings can embrace.
Meanwhile, industry organizations such as the American Pharmaceu-tical Association in Washington, DC, and the American Society of Health-System Pharmacists in Bethesda, MD, are working with the Health Care Financing Administration (HCFA) to expand reimbursement opportunities. These strategies are having some success: 1) positioning your pharmacy practice within patient management or disease management programs and 2) simply making sure that if you’re already doing those things, your billing language reflects them.
"We’ve evolved into an employee mentality, and we’ve lost the thread to the money. If we don’t embrace that, the question is where is our value?" says Daniel Buffington, PharmD, MBA, director of clinical pharmacology services at the University of South Florida College of Medicine in Tampa. "The product focus associated with pharmacy doesn’t account for the level of care or drug therapy, or the liability factors. We are going back from a product focus to a patient focus, back to our roots as primary care providers, and we must separate product from services. To me, it’s a matter of survival."
That attitude, prevalent in the industry, has helped pass new legislation in Wisconsin, West Virginia, Washington, Oklahoma, Missouri, Indiana, New Mexico, New Jersey, and Mississippi. Legislators in those states have written pharmacists into state-level Medicaid plans or supported them as qualified to take part in reimbursement for state-mandated insurance for services such as diabetes management training or immunization plans.
Wisconsin’s reimbursement model is notably progressive. It provides nearly 50 cognitive service billing codes pharmacists can pursue, with fees ranging from $9.08 to $38.55.
But setting up the process is one thing, getting a third-party payer to pony up has been another. As Buffington puts it, "Every claim I send is a no’ waiting to happen."
"What excites third-party payers are things like, Let’s deal with hypertension as a disease,’" says Dale Christensen, PharmD, at the University of Washington School of Pharmacy in Seattle. "This is the marriage of clinical practice and pharmacy." Pharmacists should refer to cognitive services anything from drug therapy review and counseling to interaction screening, pharmacokinetics, or pain management as "medication outcomes management" and not disease management, he advises. "That implies doctors, and what we’re doing is not case management either."
In Christensen’s home state, pharmacists receiving reimbursement for Medicare recipients under the Washington Pharmacist Care Project had greater clinical success during the 20-month drug intervention program, which also saved the system $13 on average for every intervention event. The state also has a pediatric asthma reimbursement plan that pharmacists can pursue, and an immunization plan that HCFA reimburses. West Virginia, he says, also has a Medicare-reimbursed immunization plan for patients over 65.
Christensen says much of this progress can be tied directly to new billing language adopted in 1992 and effective this year for Medicare patients. The law extends the scope of "eligible providers" and includes pharmacists among the new providers who can train to conduct specific programs and then bill for them. Diabetes care was one service focused on, and Christensen says warfarin therapy also fell under new language.
Pharmacists who target chronic diseases with known compliance problems and market themselves to third-party payers, physician groups, and patients should note that this is easier if the physician is under a capitation plan. He adds that high cholesterol, anticoagulation, asthma, diabetes, and immunizations are good starting points. "These are the kinds of things we’re already leading clinics on."
Every "no" at the end of a claim has made Buffington more savvy on how to bill the next time. In Tampa he has set up a clinic with five to eight pharmacists and two physicians in a group practice. "We have an office for counseling, a lab and exam room, but we have no product and we have no dispensing," he says, adding that dispensing could be added later if patients want it.
New payment codes help
Buffington uses the American Medical Association’s Current Procedural Terminology (CPT) billing codes for reimbursement. He says pharmacists can tap CPT sections 99201 through 99499. They offer 20 to 30 billing codes in which pharmacists can find a set fee per code then rate them up or down at a range of $16 to $36. Different coding standards take in new or established outpatients with five codes each. Inpatients, who have three codes, have similar ranges for first time or day two onward.
"What we’re trying to do is get reimbursed directly vs. a tag team approach with a doctor. Pharmacists could also be reimbursed for discharge counseling, but unfortunately we’ve let that function fall to others [nurses]." Levels of examination and medical decision making also have CPT codes that pharmacists could pursue.
However, Buffington advises against electronic filing, which he says makes it too easy for a denial. Instead, he sends paperwork with a written note detailing the service for which he is billing.
Above all, he advises pharmacists to take a uniform approach to claims processing. "Define a treatment or algorithm plan and a reporting plan; this is what payers want to see. The perception is it’s double dipping, so separate the product and the service, and let the hospital become the claims processor for you."
Buffington suggests that pharmacists work harder to sell their services directly to physicians, but they should start small. "Doctors are at risk for the medications and the care they give based on what it’s costing the hospital or MCO. Go to them and carve out a per member, per month rate for pharmacy talents. Start with your best skills and start out with one service," he says.
He also draws a strategic analogy with hos-pital radiology. "Radiologists are not employees but contracted practitioners. A radiologist bills for the service, the hospital bills for the product." Pharmacists, Buffington says, could do the same.
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