How does a Pharmacist GET PAID for Consulting Services?

Jonathan Shores oversees the operation of a Non-governmental Organization (NGO) charged with the mission of providing free annual Influenza Immunizations, free Pneumonia Immunizations, and free MTM pharmacy services to a growing target population of 22,000 seniors aged 65 years of age or older.  Emphasis is placed on providing in-the-home immunization services and immunization services at scheduled social clinics at each of several county locations.  Particular emphasis on serving the needs of physically home-bound, socially home-bound, and economically home-bound individuals is observed.  Jon is on the front lines, as a pharmacist, providing pharmacy services; all the while laying down the track on how to be paid for these services.  We owe Jon a debt of gratitude for his work in this field and are fortunate to have him as a guest blogger today on the AudibleRx Blog page.

Pharmacists work at the short end of some pretty restrictive provider agreements: networks with severe enrollment exclusions, mandatory mail-order, parsimonious prescription promises with poison pill payoffs, onerous minimum drug purchase requirements, just to name a few. The raison’d etre for boxing providers out is always the same: a monopoly that promises great gobs of cost savings for the American healthcare system. Whether these savings ever materialize or not, depends on who you ask, and how long you are willing to listen. The promise often carries more weight than the result. The latest adventure in restraint of practice involves Medication Therapy Management, MTM. It’s like deja’ vu all over again.

There is no problem finding pharmacy consultants able to provide counseling for eligible patients. A terrific certification program sponsored by APhA, and a splendid how-to manual called, “How to Conduct a Comprehensive Medication Review: A Guidebook for Pharmacists,” by Lauren B. Angelo and Jennifer Cerulli; have served to populate the playing field. The consulting process has been well defined: locate an eligible patient, gather data, identify and perform needed services, exhaustively document all work, perform the billing, then compile everything into a comprehensive, legal and durable health record.

The problem is how to get paid for the work that is done: bill insurance companies directly for the work, or hire a third party to do the billing. A popular method of getting paid is to buddy up with one of several companies that bill MTM services. The consultant gathers some data and performs some services, enters the work into some web- forms, and collects some fee for service. There are some perilous shortcomings involved with this approach.

Consider the following excerpt from page twenty-four of “How to Conduct a Comprehensive Medication Review: A Guidebook for Pharmacists”:
“Thorough and accurate documentation must be completed for all MTM encounters with patients. Documentation helps to justify payment for the service, and it may be needed if the pharmacy is faced with an insurance audit by the payer or CMS. Any documentation resulting from an MTM encounter with a patient becomes part of the patient’s medical record. Medical records are considered legal documents. If legal circumstances such as lawsuits or suspected insurance fraud arise, medical records, including the documented MTM, can be subpoenaed for use in court.”

The parties empowered to solicit this information from the pharmacy of record include: officers of the court, insurance auditors, law enforcement officials, and Hipaa-enabled patients. Each can reasonably expect to receive a comprehensive, legal and durable health record upon request, and in timely fashion.

Pharmacy consultants who use billing companies usually do the following: collect a limited amount of defined patient data, identify and perform services, enter the data into web-forms provided on a billing company website, and then collect a fee. The data held by the pharmacy consultant is often discarded after the fee is received. The billing company evaluates the data entered into the web-forms, creates a billing plan, bills the insurance, and then pays the pharmacist fee. The two parties seldom collaborate to combine the separate pools of information into one complete whole. The comprehensive, durable and legal health record that should be conserved by the pharmacy provider seldom results.

Billing companies negotiate exclusive provider agreements with many of the largest insurance providers. These small companies with limited resources have pledged to consult tens of millions of patients who are federally entitled to Medication Therapy Management services! Each billing company serves not as a convenient “gateway” to billing an insurer, but rather as an exclusive “gatekeeper.” A pharmacist who consults a patient who is insured by a contracted insurer must utilize the billing company contractor to get paid, even if the billing arrangement fails to meet minimally legal conventions for keeping health records.

These MTM billing arrangements restrain the practice of pharmacy consulting, foster poor record keeping practices, limit access to healthcare services, rob patients of health benefits and cost savings, and prevent the public from benefiting from the “best and the brightest” people our profession has to offer. Add them to a malignant list. Monopolistic arrangements are a common thread in the fabric of pharmacy practice, and dealing with them has become an integral part of the job. Expect to see such agreements occur again and again… and all over again.

“How to Conduct a Comprehensive Medication Review: A Guidebook for Pharmacists,” Lauren B. Angelo and Jennifer Cerulli, 2014 The American Pharmacists Association

Thanks to Jon for the post.

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