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Billing for Patient Care Services
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Billing for Patient Care Services Resource Center 

ESSB 5557 - Washington's Recognition of Pharmacists as Patient Care Providers

Pharmacists are under utilized healthcare providers. They are extensively trained in medication management that would meet a critical need for patients suffering from chronic diseases or needing preventative health care services. Within the scope of practice of pharmacists in Washington state, they can collaboratively prescribe and monitor medication therapy. However, patients haven’t had insurance coverage for these services. Addressing this barrier has been a priority for WSPA. In May 2015, we cleared a major hurdle. The successful ESSB 5557 gives pharmacists the opportunity to enroll in medical provider networks and bill for covered services. Pharmacists will finally be treated like other healthcare providers. 

The implementation of ESSB 5557 has been tiered. Beginning January 1st, 2016, many pharmacists practicing in hospitals and clinics have been integrated into the established  health-systems credentialing and contracting processes and have been billing and reimbursed for medical services. Beginning on January 1, 2017, commercial health plans in Washington State will be required to include pharmacists  working in other practice settings as medical providers in their participating provider networks.  

ESSB 5557 Bill Language 

Pharmacist and Other Providers Expectations

Health Plan Policy Directives

How to Begin Prepare to Bill for Patient Care Services:

1. Every Pharmacist Needs Their Own National Provider Identification (NPI)

Health care providers that are considered "covered health care providers" under HIPAA are required to obtain a NPI number. A covered health care provider is a health care provider who transmits any health information in electronic form between two parties to carry out financial or administrative activities related to health care. Pharmacists and pharmacies are included as health care providers and are eligible to apply for an NPI number. Pharmacies and pharmacists who transmit health information in an electronic format must obtain an NPI number. Provider NPI’s will be separate from a pharmacy’s NPI number. For more information or to apply for your NPI, please visit the National Plan and Provider Enumeration System (NPPES) https://nppes.cms.hhs.gov/NPPES/Welcome.do 

2. Get Your Personal Professional Liability Insurance

To become credentialed, medical insurance companies mandate that each health care provider is covered under professional liability insurance.  WSPA strongly believes that every practicing pharmacist should carry their own liability insurance in addition to that provided through their employer.  Liability insurance is the only protection against a personal malpractice claim you may have.   Individuals should understand that personal umbrella policies often exclude professional activities and malpractice is a personal claim against the individual.  If a claim is filed, the insurance company for your employer may choose to accept fault and settle, but you may not be willing to accept fault against you – and therefore may need your own protection.  WSPA recommends Pharmacist Mutual Insurance because the company covers the entire scope of the practice of pharmacy including compounding, work under a collaborative agreement and medication management.  To apply for insurance, visit https://apps.phmic.com/phl/. Insurance for an employed individual is $144 per year.   

 3. Get Credentialed  

WSPA's Contracting and Credentialing Workgroup is developing best practices and guidance for how to begin this process with the health insurance carriers. Log into your member account to access the WSPA Contracting and Credentialing Resource Center.

 4. Identify Covered Billable Services and Use the Appropriate Code
What services could pharmacists provide and bill for?
The WSPA Billing, Coding and Documentation Workgroup is putting together a guidebook to help our profession determine codes for billable services and documentation requirements.  Coming soon!

5. Submit Bill

The WSPA's Health Infrastructure Technology Workgroup is compiling resources for pharmacists to understand the systems they may need as Medical Providers to check eligibility, submit claims and document. 

Medical Provider Billing CE Course on WSPA’s Education Portal:

Since this bill requires health plans to include pharmacists in their medical provider networks, pharmacists must learn how to enroll in networks, including credentialing, contracting and privileging. Pharmacists and pharmacy technicians must also learn how to submit a medical insurance claim, including coding, billing and documentation. In order to support our members in implementation of this new law into their practices, WSPA has enlisted the credentialing, coding, and compliance support of knowledgeable professionals to develop trainings specific to pharmacy professionals.

 

To become a network provider, Pharmacists will need to submit an application. ProviderSource is an online system most of the health carriers use to collect credentialing information from providers. The "Credentialing as a Medical Provider Using ProviderSource" CE was developed in partnership with Teresa Davis, RV from ProviderSource to assist pharmacy professionals with this step. 

 

The WSPA developed this suite of Medical Billing CEs for the Pharmacy Professional as a comprehensive guide to prepare pharmacy professionals to document, code, and bill for medical services. The medical billing CEs include the following:

  • Medical Billing Module 1: Introduction to Medical Billing and Records presents medical billing and coding systems to familiarize pharmacy professionals on the new processes they must use to bill for medical services;
  • Medical Billing Module 2: Incident to and General, Direct, and Personal Supervision delineates how to utilize the ‘incident to’ rule in pharmacy practice;
  • Medical Billing Module 3: Introduction to Evaluation & Management Codes focuses on the use of these codes in pharmacy practice.
  • Medical Billing Module 4: Navigating the Medical Revenue Cycle connects the medical billing process with managing revenue cycle;
  • Medical Billing Module 5: Time Based Evaluation and Management discusses the appropriate use of time-based method in coding and billing;
  • Medical Billing Modules 6: Key Components of History in the complexity-based method of coding and billing.
  • Medical Billing Modules 7: Key Components of Examination in the complexity-based method of coding and billing.
  • Medical Billing Modules 8: Key Components of Medical Decision Making in the complexity-based method of coding and billing.
  • Medical Billing Module 9: Auditing Medical Record utilizes WSPA’s auditing tool to ensure appropriate coding and mitigate audit risks.
  • Medical Billing Module 10: Compliance Laws and Regulations focuses on complying with laws and regulations for medical billing and coding purposes.

Each of the CEs in the suite build upon the content of the preceding courses. Therefore, WSPA recommends learners begin from Module 1 of the Medical Billing CEs, and complete each course in order. In addition, these CEs include pharmacy specific case studies to highlight the role of pharmacy professionals as medical providers as well as illustrate the connection between documentation and appropriately coding and billing for these services. For a complete description and pricing click here.

 

The Medical Billing CEs are ACPE accredited for pharmacists and technicians, and are available in the WSPA Education Portal. Please make sure to sign in to the WSPA website to aid your login process to the portal and follow the instructions on the WSPA Education Portal page.  WSPA members receive a 40% discount on these CEs. The discount code is available here.

 

If you are interested in joining the WSPA and receiving discounts that membership provides, please become a WSPA member here.

 

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