What Pharmacists Need to Know to be Successful with Medical Billing

Pharmacies are now offering more services than ever before, and with that comes a more intricate billing process. Mary Stoner, president of Electronic Billing Services Inc., sat down with Drug Topics at NCPA 2023 to discuss the billing process for non-dispensing services in pharmacies, the essential forms and applications pharmacists should be familiar with, how pharmacists can train their team to navigate the process, and the importance of pharmacists using their voice to effect change in the industry.

Drug Topics: What specific challenges do you foresee in implementing the billing process for non-dispensing services in a pharmacy setting, and how can pharmacists overcome these challenges?

Mary Stoner: The top 3 challenges that I would see, 1 would be payer credentialing and contracting, education, and then the third would be the need for some level of technology. To overcome the payer credentialing piece, you can either employ clinicians that work for you that already are credentialed and contract with them with the payer or you can dedicate a team member that could work through the processes for the payer credentialing. There are also services that you can hire to do that as well. You also can connect with a payer network, kind of similar to the PSAOs, only this is on the medical side. It doesn’t give you access to all different types of papers, but it does eliminate some of the needs that you need, and will take care of some of those.

Then education, to start understanding Medicare guidelines. I always encourage that because most all payers are going to follow Medicare guidelines. If you begin to learn and understand Medicare coverage criteria, documentation and reimbursement, it gives you a good insight into what you should expect when you begin working with other payers. Medicare does publish what's called LCDs, which stands for local coverage determinations, and policy articles. Those are kind of like the coverage criteria, who qualifies and who doesn't. Many of them will [also] do webinars that will help your team. They travel the country; they do sessions where you can send your team to get educated directly from Medicare. Understanding Medicare is a great step in the educational process.

Last but not least, technology. That really needs to be a balance of cost versus value. A win-win, I believe, would be getting a system that guides your steps through the processes. So that way, no matter how much or how little you may know about those policies, it can guide you through those steps, and then performing eligibilities and all the technology pieces that are needed, can all be there. That's really why EDS partnered with Signetic, was to bring in that extra level of technology. So, we're taking my 35 years of experience in the industry and we are putting that into workflow processes inside Signetic, inside the technology system, so that way, literally, it's going to guide your steps one by one. You're going to know exactly what to do because it's going to guide you every step of the way.

Drug Topics: Could you elaborate on the essential forms and applications that pharmacists need to be familiar with when billing medical plans for non-dispensing services? What advice would you give to pharmacists on streamlining this process?

Mary Stoner: Just so you know, that's a very loaded question. It's loaded because it's all based upon, what does the provider want to be able to bill for, what services do they want to render? And so that really guides people to deciding what enrollments they need. Let's just kind of start with Medicare because that's always the starting point. Medicare, if you want to provide vaccines, you're going to need to enroll with an 855B application, either as a pharmacy or as a mass immunization service. I personally recommend pharmacy because it allows you the opportunity to build more services and it gives you more opportunities, where mass immunization limits you to flu, pneumonia and COVID vaccines. The pharmacy opens you up to bill for flu and pneumonia and COVID. If you have DSME or diabetes self-management education, you can add that to your pharmacy enrollment. Then, if you want to bill as an 855B or as a DMSE, you have to enroll as pharmacy.

If you want to do point-of-care testing, that would be an 855B but you would select the option to build as an independent clinical laboratory, then you would have to upload a copy of your CLIA waivers. Some people don't understand that CLIA waiver and I'd like to elaborate on that. People should think of that like your pharmacy license. You need a pharmacy license to dispense medication. A CLIA waiver is your authority by the state to dispense and administer point-of-care testing. That's what that CLIA waiver is.

Independent clinical laboratory and clinical practice is one of the other ones. If you wouldn't be able to provide clinical services, maybe you're in one of the states that does allow for clinical services to be able to be billed, that doesn't roll to Medicare. Medicare still isn't accepting us and accepting pharmacists as a part of that clinical care team. We’re getting much closer but we’re still not there. If you enroll as a clinical practice, you have to employ a clinician, so if you have a nurse practitioner, that clinician has to be able to work independently from a physician. You would want to fill out an 855B as a clinical practice, but then there's also what we call an 855R application that allows the doctor to reassign their benefits back to the pharmacy or back to that clinic or practice or work organization, so that's a good path there.

Now, any of your Medicaid plans, every Medicaid is going to be totally different. It's really based upon the state, what process they have, some have online processes now. You would want to check with your state for what Medicaid is going to allow. For commercial insurance, that is primarily going to be getting a start with credentialing, you have to credential, either through CAQH or through Availity. Those will allow you to get through that credentialing process. Now credentialing is typically for the individual, so that's going to be for the pharmacist, and then you would want to contract as a pharmacy. So those are definitely the pathways and most payers are not going to let you work with them. Medicaid and commercial insurance are not going to let you work with them or even contract a credential unless you've completed the Medicare process first. So that's step one.

A way to maximize that, to make it the easiest, for enrollment with Medicare is to start with getting anybody that owns 5% or more should be registered in the CMS Identity and Access system. Once you've registered there, and everyone that has ownership should be listed as an authorized official, those are the people that have the authority to be able to do things within the organization, and then once you do that, then you go into PECOS and that's where all of your applications can be done electronically. It will expedite the process; paper applications take longer to process than the electronic ones that are done inside. I highly recommend that everyone use PECOS, as well as starting out with getting that CMS Identity and Access.

Drug Topics: How can pharmacists effectively engage and train their pharmacy team to navigate this new payment model? What are the key roles and skills that team members should develop to support the successful billing of medical benefits for non-dispensing services in a pharmacy?

Mary Stoner: Pharmacy needs to first start acting like a clinic office. That's my first word of advice. Have you ever gone to the doctor and when you go to the doctor, what's the first thing they ask for when you walk in the door? They want a copy of your driver's license; they want the front and back of your insurance card. Even if you gave it to him last month, they want it again. They also confirm what is your phone number? And so those are things that we have to start doing. The other thing is that a clinic would actually run eligibility before the patient ever shows up. They've already pre-ran the eligibility. They know what your coinsurance and what your coverage is going to look like. That's where we struggle with independent pharmacy because many times pharmacies are not requiring people to make appointments. We let people just kind of walk in and out. Historically, pharmacies would advertise their advantage over competitors, that it's quick, it's easy, it's 15 minutes in and out. I believe that we as an industry really are going to have to start rethinking what that needs to look like and I think we need to move into more of a one stop health care shop than a 15 minute in and out process.

Lastly, be in a billing service that allows NCPDP processes. The one thing I must say is that true success in this industry is going to come when pharmacies stop relying on NCPDP responses to dictate whether they think services should or should not be rendered. Medical billing simply doesn't work that way. There is no guarantee of a medical billing claim to be paid. I mean, even when you call the payer and ask for an eligibility, they'll tell you right then, there's no guarantee of payment. So that means we have to take that piece of education and really put that into play. There's only so much that we can do as an NCPDP processor, that kind of narrows the field of what you put in to result into a paid plan. Because of that, NCPDP really doesn't have enough fields, they don't have all the fields that you need. When you send a claim, the claim service that's receiving your NCPDP claim, they're getting your primary insurance, it doesn't show your secondary insurance. There are a lot of things that are missing in that data.

I think we absolutely have to find a way to move away from that NCPDP process. If you are going to use that, make sure that you completely have educated yourself, you know what's covered, you know what that you've got the right documentation, you know the patient met the coverage criteria, you've added all the right modifiers, places of service is something that our industry doesn't seem to know a lot about right now. Making sure that they understand the place of service. Then you can successfully use NCPDP just to get that claim from point A to point B. Don’t Let that system be your guiding mark as to whether you should or shouldn't dispense, you need to know that. You need to understand before you go trying to dispense services, even using NCPDP.

Drug Topics: Are there any additional points you would like talk about that we haven’t touched on?

Mary Stoner: There's actually 2 that I think would be very beneficial for this industry to hear. In my opinion every pharmacy needs to be participating in our state associations and reaching out to their legislators. We need recognition as a part of that clinical care team from our federal and state governments. A more unified response becomes a louder voice. I think we need a “Horton Hears a Who” revival in this industry. We need to get our voices louder.

Secondly, I think this industry needs more path pavers. Listen, doing the hard work of moving boulders and clearing roads, it's a difficult job, it takes time, it takes energy. Time can equal money, it may take money. Not everybody is willing to participate in that but we need to be. This is our golden opportunity. I know coming out of a pandemic we're all very tired. It's been an exhausting 3 years. But now more than ever is when we need to be taking up our sword to finish this battle. CMS is now seeking public comment on allowing pharmacists to be able to provide clinical services, such as tobacco counseling, contraception, maternity care and breastfeeding services. They're even looking at forcing payers to accept pharmacists to receive these services. So that's coming in from the federal side.

We have their ear. This industry, these pharmacists are amazing. They have shown that they have the ability to participate as a part of that whole clinical care team and they can make this country healthier, but we have to continue to push for the policies. I think back to when nurse practitioners were in the issue that pharmacists are in now. They weren't allowing nurse practitioners to bill for services, but they made it and we can make it too. We just have to participate and be an active part in that, not only to help our current generations, but our future generations and independent pharmacists.