Payer Frequently Asked Questions

Carla Cobb, PharmD, BCPP, Clinical Pharmacist Practitioner, RiverStone Health, Billings, Montana, CPNP Government Affairs Council Chair

When I approach payers about paying for pharmacist-provided patient care they tend to ask similar questions. We have most of the “ingredients” in place; we now have to put it all together to create a successful “recipe”. The following are some of the common questions asked by payers:

Q: What kind of patient care service can pharmacists provide?

A: Pharmacists provide patient care as outlined in the guidelines “Integrating Comprehensive Medication Management to Optimize Patient Outcomes. Resource Guide” available here. These guidelines clearly describe the service that is provided.

Q: Are there certain pharmacists who are already trained to provide this service?

A: Many pharmacists have additional residency training or are board certified in specialty areas of pharmacy by the Board of Pharmacy Specialties (BPS). In addition, several states how have an additional credential or designation as an advanced practice pharmacist or clinical pharmacist practitioner. These pharmacists are especially trained and skilled at providing patient care.

Q: Do you have a method of billing for the service?

A: Yes. There are Current Procedural Terminology (CPT) codes for time based billing for medication therapy management services. Many pharmacists already track their services using these codes however few payers currently pay for them. They are 99605 (15 minutes, new patient), 99606 (15 minutes, established patient), 99607 (each additional 15 minutes).

Q: Does anyone already pay for these services?

A: Yes. Minnesota and New Mexico Medicaid pays for pharmacist-provided patient care services. Some private payers, such as Blue Cross Blue Shield of Michigan, contract with health systems or employers to pay for these services.

Q: Is there any evidence to show that pharmacist-provided patient care improves outcomes or reduces healthcare costs?

A: Yes. There are several published studies that show that these services improve quality measures and reduce overall healthcare costs.

1. Cobb C. Optimizing Medication Use with a Pharmacist-Provided Comprehensive Medication Management Service for Patients with Psychiatric Disorders. Pharmacotherapy 2014 doi: 10.1002/phar.1503
2. Isetts B, Brummel A, Ramalho de Oliveira D, Moen D. Managing drug-related morbidity and mortality in the patient-centered medical home. Med Care 2012;50:997-1000.
3. Isetts B, Schondelmeyer S, Artz M, et al. Clinical and economic outcomes of medication therapy management services: The Minnesota experience. J Am Pharm Assoc 2008;48:203-214.
4. Ramalho de Oliveira D, Brummel AR, Miller DB. Medication therapy management: 10 years of experience in a large integrated health care system. J Manag Care Pharm 2010;16:185-195.

Q: How can we ensure that pharmacists are actually providing this service?

A: You can audit their documentation to ensure that it meets the standards outlined in the guidelines. This has already been done by Minnesota Medicaid.

• Smith S, Cell P, Anderson L et al. Minnesota department of human services audit of medication therapy management program. J Am Pharm Assoc 2013;53:248-253

I would urge you to contact Medicaid plans and private payers in your state. These questions and answers can serve as an excellent foundation in opening a dialogue about their interest in including pharmacists to optimize medication use. Many payers are actively discussing payment methods for team-based care. They are attempting to move away from fee for service models and toward quality based payment. They are still assessing what value each member brings to the team. We need to be part of those discussions rather than reacting to them.