Billing for Care Presents Challenges and Opportunities
Strong support from pharmacy professionals and a shift in systems and workflows help pave the way for success.
Billing for care provided in the pharmacy is the profession’s greatest challenge and opportunity of this decade, and will not succeed without strong pharmacy technician support. A focus on patient care provision and billing medical insurance in ambulatory and community pharmacy practices requires a foundational shift in systems and workflows. Technicians have a role in championing the integration of services into pharmacy workflow and spearheading the process in the pharmacy.
At Duvall Family Drugs in Duvall, Washington, Sirena Kalinski, CPT, has been integral to her pharmacy’s provision of patient care services. Over the past year, she has administered COVID-19 tests and REGEN-COV subcutaneous injections to treat the disease and vaccinated hundreds of patients.
Engaging technicians in more significant roles can “drive job satisfaction, lifting pharmacy technicians into new roles and advancing them. It can drive staff retention and loyalty by empowering and educating the pharmacy technician,” Kalinski said.
Pharmacist leaders are wary of burning out technicians by increasing their responsibilities. Still, “having a chance to have a greater role with patients by administering medications and taking care of them is energizing,” Kalinski said.
She has also taken a leadership role in getting her pharmacists credentialed with health plans and identifying new services that the pharmacy can offer as COVID-19 service demand has subsided. Kalinski has talked with patients and members of the community to identify sustainable offerings to drive new patient care delivery.
Although pharmacists must be actively engaged in patient care, technicians also have a role, she said.
“They can perform patient intake, verify benefits, bill the claims, and manage the revenue cycle for medical claims by reviewing what has been paid, what needs to be rebilled, and sending invoices to patients,” Kalinski said.
Washington was the first state to pass legislation requiring plans to include pharmacists in their networks. Shirley Rullan, CPT, an account manager at Premier LTC Pharmacy in Seattle, led billing and credentialing for the group practice in the state.
“I became interested in administration work after helping the community pharmacy I worked with prepare for audits. I loved the research and understanding the back end of claims,” Rullan said. “Then I met someone, and we worked to establish a group practice. I established contacts with a provider relations manager at the health plans, which really helped.”
Starting this group practice in the early days after the legislation passed in Washington was challenging, but it got easier as the plans learned about the law change and as she learned how to navigate the process.
Technicians can take a lead role in spear- heading service delivery. In addition to credentialing pharmacists as Rullan did, identifying needed services as Kalinski did, and billing claims as both have done, technicians can do even more. Other tasks that technicians can tackle include implementing new workflows, learning and launching billing management software systems and electronic medical records in the pharmacy, and billing the claims to the plans.
In terms of billing the plans, Rullan learned the value of using a clearinghouse or software checker to make sure that claims are complete and have the correct modifiers included.
“With time, I learned the ICD-10 and diagnosis codes, [current procedural terminology] codes and modifiers, and I got good at knowing which codes to use,” she said.
Technicians can start by engaging with their state pharmacy associations to learn whether there is payment for services opportunities in their states.
State pharmacy associations may offer training in how to bill as a provider.
“I subscribed to all the plan’s email lists for newsletters and updates on billing,” Rullan said. “That’s how I learned about changes to co-pays, especially for COVID-19, and how I learned the lingo for talking with insurance companies.”
In ambulatory clinics, technicians often serve as assistants to pharmacists, make appointments, room patients, and take vitals. Their role is akin to that of medical assistants helping physicians in clinics.
Technician roles continue to expand. They can address administrative challenges because of their attention to detail, in-depth understanding of pharmacy practices and workflows, and strong technical skills, which make them ideal candidates to champion medical billing and services in pharmacies. “I am so excited by the potential of pharmacy practice, and I am passionate about pharmacy technicians’ ability to make a difference,” Kalinski said.
Jenny Arnold, PharmD, BCPS, is chief executive officer of the Washington State Pharmacy Association.
Ross M. Big win for pharmacist provider status in Washington state. May 11, 2015. Accessed March 16, 2022. https://www.pharmacytimes.com/view/ big-win-for-pharmacist-provider-status-in-washington-state