Provider Status Means More than Medicare Part B

The recognition of pharmacists as healthcare providers under Medicare Part B must remain a top priority for the profession, says ASHP's Tom Kraus, vice president of government relations.

But Kraus also wants pharmacists to pursue opportunities outside of traditional Medicare that advance payment for patient care services.

“If we want to rally around something, let’s recognize that of most of the action around payment is at the state level,” he said. “This is where progress is being made.”

Kraus was an invited speaker for Innovations in Pharmacy Training and Practice to Advance Patient Care: A Workshop, an ASHP-cosponsored forum convened by the National Academies of Science, Engineering, and Medicine (NASEM) in Washington, DC.

The May 29–30 workshop brought together experts in pharmacy practice and education to discuss pharmacy deserts, financial sustainability, the well-being of the pharmacy workforce, and how to ensure that pharmacy education evolves to meet the needs of today’s learners and the profession.

The need for pharmacists to be appropriately reimbursed for their clinical services was a common thread connecting the broader agenda topics. ASHP CEO Paul W. Abramowitz told workshop attendees that advocacy in this area remains “a key priority for [ASHP], to help ensure that pharmacists are part of each and every care team and have the resources necessary to provide care for their patients in all sites of care.”

Kraus made three specific advocacy and outreach recommendations that resonated throughout the workshop.

Enact and expand provider status legislation in all states. Most states have now passed some version of provider status legislation, but the specifics of the laws vary. What’s important, Kraus said, is for state provider status laws to require both commercial insurers and state Medicaid plans to appropriately reimburse pharmacists for their clinical services.

Kraus pointed out that advocacy aimed at normalizing appropriate reimbursement in the states can influence federal policy.

“As a federal lobbyist, I would love to be able to go to a congressman and say, ‘Did you know that your seniors in your state are the only people who can’t access a pharmacist’s services?’ That’s a very different conversation than saying, ‘Please, won’t you support pharmacist provider status?’”

Maximize opportunities for pharmacists to bill Medicare for services delivered incident to a physician’s care. Kraus urged attendees to advocate for regulatory and legislative change to broaden the use of incident-to billing. This mechanism allows reimbursement through higher-paying procedural codes that better reflect the complexity of the pharmacist’s services.

“Even if we secure [federal] pharmacist provider status, it will be below the Medicare fee-for-service rate,” Kraus noted. “The only way we get the full payment amount is if we partner with the physician for incident-to billing, and that is paid at the full physician rate.”

Take advantage of billing opportunities in Medicare Advantage. Enrollment in Medicare Advantage plans has been steadily climbing and now exceeds enrollment for traditional Medicare — and that opens new avenues for reimbursement.

“Medicare Advantage can cover a pharmacist as a provider. There’s nothing stopping a payer in any state from doing that,” Kraus said. Establishing a payment process for pharmacists, he noted, is largely a contracting issue between the Medicare Advantage plan and the pharmacist’s employer.

By working all three of these reimbursement avenues at once, Kraus said, the profession can “make substantial progress as we continue to fight for Medicare provider status.”

A related theme on scope of practice for pharmacists also inspired discussion among the workshop attendees.

Mary Ann Kliethermes, director of medication safety and quality at ASHP, described how variations in state scope-of-practice acts make it difficult for payers to draft national policies covering pharmacists’ services.

“There needs to be some kind of standard process,” Kliethermes told workshop attendees. “Just like when you see a physician, you know there’s a history and there’s a physical, there’s something that happens, so that we can use those elements in order to be standard, reliable, and consistent.”

She also emphasized the importance of revising state insurance regulations to list pharmacists as healthcare practitioners who must be paid for services provided within their scope of practice.

ASHP will review the workshop committee’s upcoming summary and evaluate and act on recommendations that address members’ key concerns.