This document summarizes payment reform for pharmacists and barriers they face to reimbursement for expanded services. While pharmacists now provide direct patient care services beyond dispensing prescriptions, compensation models have not caught up and often do not provide reimbursement for new roles. Federal programs like Medicare do not recognize pharmacists as providers, and some state laws are starting to address this by enabling pharmacist billing and allowing expanded care services and prescriptive authority. As primary care physician shortages grow, states may further advance pharmacists' provider status to boost access to care.

1. 12/29/15, 12:08 PMPayment Reform for Pharmacists Remains Variable
Page 1 of 3http://www.pharmacytimes.com/publications/directions-in-pharmacy/2015/december2015/Payment-Reform-for-Pharmacists-Remains-Variable
Login | Register | Subscription
PRACTICE SETTING
Payment Reform for Pharmacists Remains Variable
Nan Myers
Published Online: Monday, December 21, 2015
A shortage of primary care physicians (PCPs) is looming in many areas of the United States. However,
although projections indicate this situation will get worse before it gets better, unexpected positive changes
are happening for pharmacists.
The Role of the Pharmacist Is Changing
To meet the health care shortfall, which results partly from health care reform, pharmacists are taking on
expanded responsibilities. Most community pharmacists no longer stay exclusively behind the counter.
Instead, they are developing new skills beyond the traditional prescription-dispensing function. Pharmacists
now provide direct-care services, such as immunizations, point-of-care (the delivery of health care services
to patients at the time of care), wellness and prevention screenings, medication therapy management,
chronic condition management, patient education, and counseling.
These roles are often part of team structures and are carried out in a much wider range of settings than the
traditional drugstore or hospital. These settings include inpatient facilities (hospitals, nursing homes, and
rehabilitation centers); outpatient, urgent care, and ambulatory clinics; patient centered medical homes
(PCMHs), and accountable care organizations (ACOs). The PCMH is a care delivery model whereby patient
treatment is coordinated through a patient’s PCP physician to ensure the patient receives the necessary
care when and where they need it, in a manner they can understand. ACOs are groups of doctors,
hospitals, and other health care providers, such as pharmacists, who work together to offer coordinated care
to their Medicare patients. The goal of an ACO is to ensure that patients, especially those who are
chronically ill, receive the best care when they need it and avoid unnecessary duplication of services which
raises costs.
Studies of pharmacists who provide medication therapy management (MTM) services show that such
services can improve outcomes and reduce costs. These services are typically provided through
collaborative practice agreements. In most states, pharmacists can modify prescriptions under a
collaborative agreement that allows pharmacists to address drug-related adverse effects and improve
therapeutic outcomes for patients.1
The compensation model still mostly lags behind these new
opportunities.
How Can Pharmacists be Compensated for Providing New Services?
Community-based pharmacists are considered to be among the most accessible health care practitioners.2
However, when they branch out from filling prescriptions, they find there is often a problem in obtaining
reimbursement for these services. In the current environment, pharmacists can bill patients directly on a
cash-transaction basis, provide services under a third-party insurance-contracted service, or use
pharmacist-specific current procedural terminology (CPT) codes.
Medicare and Medicaid compensation policies also limit pharmacists’ ability to practice in new areas,
particularly within integrated care teams. For example, under Medicare Part B, pharmacists are not included
in the statutory definition of providers and, therefore, cannot directly bill for patient care services. In addition,
many state and private health plans align their payment policies with Medicare policies and, as a result, do
not allow pharmacists to bill directly for patient care services.3
These situations are not unusual. As we look to 2016, the hope is that as pressures continue to increase on
health care providers, the value of pharmacist-provided services will be recognized and reimbursed. Some
MORE ARTICLES >>
Heart Failure and Afib: A Circular Process
Heart failure and atrial fibrillation often coexist.
8 Conditions to Check in Cerebral Palsy Patients
Patients with cerebral palsy are often faced with
secondary health conditions such as diabetes,
asthma, and hypertension.
Can Probiotics Help Prevent Diarrhea?
Probiotics have nearly 100 possible benefits and
uses. Among these uses, the prevention and
treatment of diarrhea is becoming increasingly
common, especially in children.
Zurampic Approved to Treat Gout-Associated
Hyperuricemia
AstraZeneca’s lesinurad has been approved by the
FDA to treat high blood uric acid levels associated
with gout, when used in combination with a xanthine
oxidase inhibitor.
News Videos Resource Centers Continuing Education Community Publications
Latest Articles

2. 12/29/15, 12:08 PMPayment Reform for Pharmacists Remains Variable
Page 2 of 3http://www.pharmacytimes.com/publications/directions-in-pharmacy/2015/december2015/Payment-Reform-for-Pharmacists-Remains-Variable
change may happen as alternative payment models (APMs) and fee-for-service (FFS) quality initiatives
continue to take hold. In 2018, APMs and FFS linked to quality are forecast to hit 50% and 90%,
respectively, of reimbursements.4
Currently, pharmacists who practice in walk-in clinics, urgent care facilities, or inpatient or outpatient
facilities may be able to negotiate contracts with different payers or self-insured employers. There is also the
“incident to” concept where a pharmacist bills services under a physician’s National Provider identifier
number (issued by CMS). In this case, reimbursement is 100% of the Medicare fee schedule as opposed to
only 85% when the service is billed under the pharmacist’s number.
Depending on the payer, a pharmacist may also use some CPT codes when seeking reimbursement. Three
pharmacist-specific CPT codes (99605, 99606, 99607) were established for the delivery of medication
therapy managed services. These codes are used by Medicaid, private health insurers, or Medicare. MTM
for Medicare Part D beneficiaries is among the most prominent types of direct patient care services that are
reimbursed by payers today.
How Does the Law Play a Role?
States, too, are very slowing recognizing the value of pharmacists in direct care. The first to implement
changes are Washington, California, and Oregon. On January 1, 2016, Washington will enable pharmacists
to bill for their services just as a physician bills a patient for theirs. With such laws, these states lead the way
in requiring health insurers to consider pharmacists as health care providers alongside doctors and nurses.
In California and Oregon, pharmacists will be able to prescribe contraceptives. After a brief screening that
will include a questionnaire about the woman’s health and medical history, the pharmacists will assess
whether to prescribe birth control to her based on health history and lifestyle. Then the pharmacists will
either dispense the birth control or refer the woman to a physician. The pharmacists will be reimbursed by
payers if the woman carries insurance.
As long as Uncle Sam does not widely recognize pharmacists as health care providers in federal programs,
pharmacists will have to pick and choose opportunities to obtain reimbursement. This is, however, a path
that can lead to a better situation at the state level. Should the shortage of PCPs continue and affect more
high population areas, state legislators, like those in Washington, California and Oregon, are likely to
consider efforts to give pharmacists the provider designation status, which should result in remuneration for
services.5-8
Nan Myers is a content strategist who works with health care clients to tell their stories through writing for
newsletters and published articles, while also coordinating media relations.
References:
1. National Center for Chronic Disease Prevention and Health Promotion. A program guide for public
health: partnership with pharmacists in the prevention and control of chronic diseases. CDC website.
http://www.cdc.gov/dhdsp/programs/spha/docs/pharmacist_guide.pdf. Published August 2012.
Accessed December 1, 2015
2. Avalere Health. Developing trends in delivery and reimbursement of pharmacist services. NASPA
website. http://naspa.us/wp-
content/uploads/2015/11/103015_Avalere_NACDS_WhitePaper_LP_Final.pdf. Published October 30,
2015. Updated November 4, 2015. Accessed November 16, 2015.
3. Social Security Administration. Title XVIII—Health Insurance for the Aged and Disabled. SSA website.
www.ssa.gov/OP_Home/ssact/title18/1800.htm. Accessed December 9, 2015.
4. Tefera L. Delivery system reform and the hospital value-based purchasing (HVBP) program.
SlideShare website. www.slideshare.net/SAGES_Updates/dr-lemeneh-tefera. Published September 3,
2015. Accessed December 9, 2015.
5. Maine LL, Knapp KK, Scheckelhoff DJ. Pharmacists and technicians can enhance patient care even
more once national policies, practices, and priorities are aligned. Health Aff (Millwood).
2013;32(11):1956-1962. doi: 10.1377/hlthaff.2013.0529.
6. Smith M, Bates DW, Bodenheimer TS. Pharmacists belong in accountable care organizations and
integrated care teams. Health Aff (Millwood). 2013;32(11):1963-1970. doi: 10.1377/hlthaff.2013.0542.
7. Yap D. APhA to HHS: lack of provider status a barrier. American Pharmacists Association. website.
www.pharmacist.com/apha-hhs-lack-provider-status-barrier. Published November 4, 2013. Accessed
June 18, 2015.
8. Marotta R. Regional pharmacy trends: the state of provider status. Pharmacy Times website.
www.pharmacytimes.com/publications/career/2015/pharmacycareers_february2015/regional-

3. 12/29/15, 12:08 PMPayment Reform for Pharmacists Remains Variable
Page 3 of 3http://www.pharmacytimes.com/publications/directions-in-pharmacy/2015/december2015/Payment-Reform-for-Pharmacists-Remains-Variable
pharmacy-trends-the-state-of-provider-status. Published February 16, 2015. Accessed June 18, 2015.
Tweet your thoughts about this article @Pharmacy_Times
Join the conversation on the Pharmacy Times Facebook page
Sign up for our eNews to get the latest news and updates delivered to your inbox
MJH Associates
American Journal of Managed Care
Cure
MD Magazine
ONCLive
OTCGuide
Specialty Pharmacy Times
Targeted Oncology
About Us
Careers
Contact Us
Feedback
Advertise With Us
Terms & Conditions
Privacy
Press Room
Intellisphere, LLC
666 Plainsboro Road
Building 300
Plainsboro, NJ 08536
P: 609-716-7777
F: 609-257-0701
Copyright PharmacyTimes 2006-2015
Pharmacy & Healthcare Communications, LLC.
All Rights Reserved.
Latest Issues