Jeff Rochon, PharmD, chief executive officer, Washington State Pharmacy Association, champions efforts to pass state legislation, including SB 5557, which will increase the number of pharmacists in health plan preferred provider networks. Ultimately, this will lead to improved patient access to the expertise of pharmacists in hospitals, clinics, community pharmacies, and nursing homes.

In an Insight Session titled “Advancing Collaborative Patient Care—Lessons Learned from Washington State,” presented on August 27 at NACDS TSE in Denver, Rochon described the history of state-level provider status in Washington State, including lessons learned from Washington’s efforts related to state-level provider designation and how these changes can impact patient care.

Over the past several years, Rochon and his colleagues have worked closely with health plans to facilitate the successful implementation of SB 5557, signed into law in May 2015, which governs integrated provider network enrollment processes, mechanisms for appropriate coding, and billing medical claims with necessary documentation and compliance.

Rochon says pharmacists must learn how to enroll in participating provider networks while navigating issues surrounding contracting, credentialing (documented evidence of professional qualifications), and privileging (authority to render specific diagnostic, procedural, or therapeutic services, granted by a healthcare institution to a provider). In addition, pharmacists need to understand medical benefit coverage and medical billing processes, health information technology, and health information exchange.

Rochon described the credentialing process wherein healthcare professionals, including pharmacists, require documenting and demonstrating a healthcare professional has attained the credentials to provide certain patient care services within the scope of care in a particular setting.

Once part of a healthcare provider network, pharmacists must familiarize themselves with medical billing nuances. “Billing medical claims is very different from billing pharmacy claims; there is nothing to integrate into the pharmacy practice software,” he said. Existing platforms in health systems setting, noted Rochon, are very expensive—about $10,000 per year per provider and therefore cost-prohibitive for pharmacies. So, Rochon says his organization exploring other software in development that will better fit the needs of pharmacy billing.

With an effective pharmacy billing system in place, the resulting revenue can be considerable. Rochon described one payer experience involving four medical clinics. In this practice, more than 3,000 claims were submitted, totaling $203,445 paid to pharmacists over a 10-month period in 2016.

The ultimate goal, says Rochon, is for pharmacists in hospitals, clinics, and community pharmacies to successfully enroll in provider networks and submit medical claims—primarily involving evaluation and management consultation (E&M) codes—for provided services.

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