Diabetes Self-Management Education Accreditation Provides Billable Opportunity for Pharmacists

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This accreditation allows pharmacists to give diabetes education to patients with Medicare and receive Medicare reimbursement.

Travis Wolff, PharmD, BCACP, the CEO and founder of PharmFurther, and director of CPESN Medical Billing Special Purpose Effort in Sapulpa, Oklahoma, joins Pharmacy Times to continue our discussion about diabetes self-management education (DSME), an accreditation that pharmacies can get which allows pharmacists to educate patients on self-managing diabetes. You don't want to miss this follow-up interview with Wolff, who discusses the current difficulties associated with getting DSME accreditation and performing medical billing for their work helping with diabetes, and the criteria pharmacists need to meet before applying for accreditation.

Key Takeaways

  • Pharmacists take on many responsibilities that are not acknowledged by CMS, and they face many accreditation denials (like for DSME). Pharmacists can take different steps toward provider parity.
  • Pharmacists should document patient care processes and outcomes to demonstrate that there is value in pharmacist-provided DSME services.
  • DSME accreditation requires 6 standards, and most pharmacies already have some of these standards.
  • Pharmacists can benefit from training programs that make DSME accreditation easier and more accessible.

PT Staff: With the growing epidemic of diabetes [there are so many more patients]. I feel that it's so important that patients know these resources [like DSME] exist, but I'm also curious about your point of view. How does communication about this program increase? What else is needed for patients to have confidence in going to the pharmacist knowing that they're going to receive the care that they deserve?

Travis Wolff, PharmD, BCACP: Being the most accessible person on the healthcare team, I feel like they're already coming to us. I feel like we also get stuck and not wanting to step on the physicians’ toes, and I think that's absolutely true. I think that we are not trained the way that I wish we were in diagnosis, and there are things that absolutely we need a physician to have a pair of eyes on, but I think that we can work towards more of this provider parity.

You know, my goal is to be shaking the [hand of the] president of the United States sometime in my career, whenever the centers for Medicare and Medicaid Services (CMS) gives us the full provider status, because it's hard. Medical billing is so difficult for pharmacists. And even if you're taking great care of your patient and you're producing very good outcomes, which is the number 1 goal, the legislators and the payers are measuring those outcomes by paid dollars.

You can be working your tail off in clinical encounters, but if you're not billing those out, they don't see the good that you did—CMS ties it back to the provider and they got paid for it. So you could run a full-blown medical clinic for free and not ever get paid as a pharmacist, even if you have tremendous patient outcomes. But the doctors that you're sending all the requests to and the changes to [will get paid], all the things they get paid to manage that patient's health. CMS is following the dollars [which are with doctors].

My concern is with all these grant dollars. Now state Medicaids are paying for DSME, but my concern is that our legislators of these various different states are going to come back and say, “Well, we gave $100,000 in our budget to pharmacists to manage diabetes, and we've only paid $10,000 out, so I guess pharmacists are not capable of doing what we thought they were,” even though pharmacists have worked their tail off taking really good care of patients. The payers, the decision-makers of the payers, and the legislature types of people are not ever going to see the rejections (accreditation denials and attempts to get progress made). They're just looking at paid dollars.

One of the big A-Ha! moments in my work with the CDC was on DSME, actually. We had pharmacies that had a ton of rejected claims on the medical side, and sometimes it wasn't even for diabetes. Sometimes it was for antibodies for COVID-19 or COVID -19 vaccines, and CMS didn't even know there was a problem and how hard it was to get paid for DSME. Whenever I started that project, they were saying “We don't have any of those rejects,” so we had to really work hard.

The whole problem with that process, Erin, is that since the pharmacist does not have that provider status (provider parity is what we're calling it now because we're not trying to replace the physicians, we're trying to work in synergy with them), because we don't have that, services like DSME are done by a pharmacist but are billed on the pharmacy National Provider Identifier Standard (NPI) because the pharmacy is an accredited provider with Medicare.

Going back to your question, “How do we empower patients to get to that?” I think they're already coming in. I think if we're not getting their medical card and letting them know [that] this is an office visit with payable time, just like at a physician, then they're not of the mindset as to what kind of recommendations we're making the ability to affect their outcomes. And when pharmacists do bill out, the outcome is unknown.

When we bill a pharmacy drug, we know within a matter of seconds; [however], with medical billing, you put all the things in the blanks that you're not sure if they're in the right blanks, then you wait 10 to 14 days for a response. And then the patient might have a deductible. They might have a different copay. Maybe you're out of network and then pharmacists get scared, and they want to reverse those claims and not bill it. But again, if we reverse it, no outcomes are measured because there was no payment. Then the patient's mindset does not change to “Hey, this is a medical provider [and] I am getting a service beyond dispensing,” because they're not tracking out of their pocketbook either.

PT Staff: Thank you so much, that was a fabulous answer. How can pharmacists get this accreditation? They deserve to know.

Travis Wolff, PharmD, BCACP: To become accredited for a DSME site, there are 6 standards you have to reach. Currently, the standards are reviewed and updated every 5 years. The 6 standards are pretty simple to meet, okay, and pharmacies meet a lot of those already. It's just a matter of documenting how you meet those standards.

And just very briefly, standard 1 is support for the DSME services. Standard 2 is population and service assessment of your demographics. Standard 3 is making sure the DSMES team is properly set up with the continuing educations (CEs) that are needed, and the right qualifications: registered nurse, registered dietitian, or licensed pharmacist. Standard 4 is how you're going to deliver and design those services. They want to see how you're going to perform your office visits in your classes. Standard 5 is proof that you had a person-centered program—so you're just submitting a patient chart for a completed patient in your program. And standard 6 is measuring and demonstrating outcomes.

We want to make sure that we're looking for room for improvement every year, that we're documenting our approach to that improvement and we're seeing the outcome. So thinking through that, there are ton of free resources out there for pharmacists, and they can follow it step-by-step to meet those standards. They don't have to pay for a bootcamp. What I find is pharmacists don't realize the things that they already have in operation under their roof that qualify for some of these standards. And if they do have it and they do find that it qualifies, they don't know how to document it appropriately.

The Bootcamp for NCPA that I teach is a 6-week long program where we teach for an hour and then we have a little bit of homework every single week. The standards that take the longest time are the first thing we teach, and pharmacists like to go 1,2,3,4 (they like the order) and then the end of the 6 weeks, if you kept up with homework, then you're ready to submit for accreditation.

So [with the] boot camps— and there are other trainings besides a boot camp out there, so with all of those—you're paying for time. You're saving yourself so much time. If you don't go through like a boot camp like the one that I teach, what I see often is that people are spending 6 months or a year trying to get everything in line, and it's not hard. We're just trying to show that we do have a demand in our demographics, we do have a reasonable way to set up our classes, we do have an approved curriculum, and we are going to measure and monitor our outcomes.

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