SUSTAINABLE BILLING, REIMBURSEMENT, AND PAYMENT MODELS

To advocate for reimbursement, pay parity, and financially sustainable models related to cognitive services of pharmacist-accountable services, regardless of site of care; further,

To educate the pharmacy workforce and stakeholders about financially sustainable models of care; further, 

To advocate that compensation for healthcare services be commensurate with the level of care provided, based on the needs of the patient; further,

To advocate for the development of consistent, transparent billing, reimbursement, and alternative payment model policies and practices by both government and commercial payers.

Rationale

The National Academy of Sciences recommends that payers, including Centers for Medicare & Medicaid Services (CMS), commercial insurers, and self-insured employers shift payment for healthcare services toward a hybrid model that includes fee-for-service and capitated payments, and that these models pay prospectively for interprofessional, integrated, team-based care. Due to lack of federal provider status for pharmacists and subsequent inability to directly bill Medicare as care providers, organizations and practices have become creative in maintaining financial sustainability of pharmacist services. Financial sustainability for services provided by pharmacists has been achieved using a variety of models. Some settings utilize indirect funding, while others take advantage of some of the limited direct insurance billing opportunities to fund pharmacist patient care. Direct billing opportunities vary based on the setting (e.g., hospital-based versus physician-based practices) as well as state-specific laws and regulations. Medicare, Medicaid, and commercial health plans may reimburse pharmacists for certain services, while some will require direct contracting with the health plan. Several states have passed pharmacist state provider status laws or reimbursement parity laws allowing for reimbursement for direct patient care pharmacist services by state Medicaid or commercial plans.