Under Construction: Obtaining Reimbursement for Clinical Services. Dan Buffington, Pharm.D., M.B.A.

Transcription

1 Transforming Pharmacy Reimbursement: A Roadmap for Success Under Construction: Obtaining Reimbursement for Clinical Services Dan Buffington, Pharm.D., M.B.A ASHP Summer Meeting

2 Billing for Clinical Services Daniel Buffington, PharmD, MBA Clinical Pharmacology Services, Inc Tampa, Florida

3 Presentation Outline: Introductions Development of Advanced Practice Models Reimbursement Trends and Issues Established Reimbursement Strategies Reimbursement Case Studies Questions and Answers

4 Session Objectives Explain issues surrounding billing for pharmacy services. Describe options for coding and billing pharmacy services under APCs. Delineate steps required to obtain authorization from payers to provide services. Explain documentation required to appropriately bill for pharmacy services. Identify corporate compliance standards and their relationship to pharmacy billing services. Demonstrate skills that enable optimal reimbursement for clinical services.

5 Developing an Advanced Pharmacy Practice Model Positioning Your Skills to Meet The Needs of the Healthcare Market Clinical Pharmacology Services

6 Scope of Services in a Practice Model What do you want to create in a pharmacy practice model?

7 Scope of Services in a Practice Model Services? Products? Practice Setting? Patient Population(s)? Marketing? Reimbursement? January 1 December 31

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9 Scope of Clinical Pharmacology Service s Practice Model Medications? CLINICAL RESEARCH TRIALS Principal Investigators & Research Design MEDICAL EDUCATION Continuing Medical Education Quality CONSULTING Health Systems Cost PATIENT CARE CONSULTATIONS Drug Interactions Medication Counseling Disease State Management Therapeutic Drug Monitoring EXPERT REVIEW & TESTIMONY Legal cases involving pharmacology issues

10 Patient Care Consultations Inpatient / Outpatient Medication Review & Counseling Drug Information Collaborative Practice Model Limited Diagnostic Testing Disease Management TDM Medications? PATIENT CARE CONSULTATIONS

11 Patient Care Consultations Physician Referred Patient Self-Referrals Managed Care Plan Programs & Contracts Medications? Spin Off from Other Activities Advertising Local TV Interviews PATIENT CARE CONSULTS

12 Clinical Research Trials Phase I-IV Multi-specialty Collaborative Practice Outpatient - Inpatient Clinical Research Staff Regulatory Processing CLINICAL RESEARCH TRIALS Principal Investigators & Research Design

13 Medical Education Special Events Speaker Bureaus Educational Round Tables New Product Launch Internet Pharmacology Series Employer Groups Benefit Committees MEDICAL EDUCATION Continuing Medical Education

14 Consulting: Health Systems Hospitals Home Health Care Practice Development Managed Care Organization Pharmaceutical Companies Quality Cost Cost CONSULTING Health Systems

15 Expert Review & Testimony Diversity of case mix (MedMal, Criminal, Civil) Technical expertise Similar to standard practice (med consult) Time based billing Limited Liability Rapid payment cycles EXPERT REVIEW & TESTIMONY Legal cases involving pharmacology issues

16 Reimbursement Trends and Current Issues Understanding your practice environment

17 We Need To Make Up Our Minds and Commit Products are products Services are services Product s Patient Care Which can you control? Which one is controlled externally?

18 Leading causes of death in the US (1994 figures) JAMA 1996 Diabetes 53,894 Pneumonia 75,719 Accidents Pulmonary Disease Adverse Drug Reactions Stroke 90, , , ,508? Cancer 529,904 Heart Disease 743, , , , , , , , ,000

19 Need for Increased Need for Clinical Services Increased physician prescribing Medication waste Rising cost of medications Adverse drug reactions Drug Interactions DSM and compliance MEDICATION > $76 billion annual inappropriate use of medications

20 National Pharmacy Reimbursement Trends Disease State Management (DSM) Collaborative Practice Modification of State Pharmacy Practice Acts Expansion of Ambulatory Care Services Retail Specialty Centers Expanded Roles and Opportunities for Pharmacists Increase in Salaries Shortages of Pharmacists in All Practice Settings Decreasing Product Reimbursement Expanded Need for Consultative Services (not product)

21 Why Should We Pay You? Payer s Perspective Don t you already get paid for the services you provide? Why should we pay you? You already make too much for the product anyways, don t you? Pharmacy costs are sky rocketing, why should we pay you more? We don t know what you can do to help, are you qualified? We already have physicians.why do we need you to help isn t that duplication of services? If we pay you, then there are one hundred other people who want to get paid too!!! Don t nurses do what you do?

22 Do You Know How You Get Paid Today? What generates your income? Who generates your income? Who is responsible to ensure that you continue to have an income? Pharmacy Who can impact your income? Employee or Practitioner?

23 Healthcare & Finance Administration s (HCFA) Current Position National demonstration projects (Mississippi & Washington) Recent modifications to approved provider list Dietician and Pastoral Care Target for inclusion of Pharmacists as Providers CMS broadens definition of Provider Numbers Universal provider number (all healthcare practitioners) HIPPA s impact on the future of pharmacy practice

24 HCFA finalizes rule on Medicare coverage of outpatient diabetes self-management training Pharmacists recognized as possible team member Starting February 27, 2001 HCFA will pay for services Qualified Pharmacists Multidisciplinary Team members must have a CDE and Dietitian Payment to employer (hospital or DME Pharmacy) Does not pay pharmacists directly, but does recognize role Defines patient education content and roles Quality improvement and outcome measurements

25 Reimbursement for pharmacists cognitive services in the inpatient setting Elizabeth Landrum Michalets and Ellen Williams Am J Health-Syst Pharm. 2001;58:164-6 (Vol 58 Jan 15, 2001) North Carolina Two Hospitals (800 beds total) Two years of data collection Utilized CliniTrend software for data tracking and analysis Utilized CPT coding for service descriptions

26 Reimbursement Strategies Requesting Authorization

27 Requesting Authorization to Provide Services Clinical service/team structure influences choice of billing methods Patient s Insurance Carrier type influences billing choices and coverage Insurance information on the insurance card or in the patient chart Authorization Department Medical Director (not Pharmacy Director) Specialty Service (not primary care) Case-by-Case approval vs. Provider Number Templated authorization to treat consent form

28 Requesting Authorization to Provide Services Director of Pharmacy Director of Quality Assurance Director of Case Management Director of Utilization Review Medical Director Approved Need for Services Authorization Department? Cover letter with supporting information: Declined Statement of medical necessity Brief description of services Brief description of the value to both patient and provider Statement of estimation of charges Brief biography (focused on skills and training)

29 Requesting Authorization to Provide Services Hospital-based Service Integrated with facility billing Insurance info captured during admissions No additional consents or waivers required May require additional authorization Billing opportunities: Managed Care contracts Carve-out of facility payment Modified NDC coding models APC Private Service Private practice billing (as a specialist) Insurance info captured during admissions Unique consents or waivers required Will require request for authorization Billing opportunities: Managed Care contracts CPT coding models (Private) CPT coding models (Collaborative)

30 Authorization Request Approval Approved Specific events/services Not dependent upon a provider number Inpatient or Outpatient Request written confirmation of approval Confirm need for any specific documentation Confirm proper contact for billing

31 Corporate Compliance Standards Service Structure & Staffing Model Establish service referral pathways Communications pathways with the payer s authorization department Accounting and Billing processes Medical Services & Medical Staff Office (Internal Credentialing) Nursing Services Risk Management Informed Consent & Authorization to Treat HIPAA Compliance IT Department Medical Records

32 Reimbursement Strategies Developing a game plan

33 Medical Coding Models Prospective Payment System (PPS) Ambulatory Payment Codes (APC) J-codes (J) Current Procedural Terminology (CPT) Contracted Services

34 Prospective Payment System (PPS) Requires payment for all costs of SNF related services. Includes drug therapy and other non-therapy ancillary services. Wording of rules addresses certain items of skilled coverage regarding the overall management and evaluation of the care plan and patient education.

35 Medical Coding Models Prospective Payment System (PPS) Product & Service Facility (Clustered) Ambulatory Payment Codes (APC) J-codes (J) Current Procedural Terminology (CPT) Contracted Services

36 Ambulatory Payment Codes (APC) APC (ambulatory payment classification) Drives Medicare reimbursement for the hospital Linked to PPS Must list all diagnostics, procedures, and drugs No re-submission of claims Provides a platform for expanding CPT coding and capture of overhead related to hospital based ambulatory care specialty services.

37 Ambulatory Payment Codes (APC) Anticoagulation Monitoring Services Charges are associated with the Facility and not directly attributable to the individual Pharmacist or Pharmacy department ( institutional model ) Assess impact of incorrect billing for services Develop practice guidelines to minimize financial risk Facility exercise financial and clinical judgment in selection of drug therapy

38 Medical Coding Models Prospective Payment System (PPS) Product & Service Facility (Clustered) Ambulatory Payment Codes (APC) Product / Service Hospital Based (Clustered) J-codes (J) Current Procedural Terminology (CPT) Contracted Services

39 J-codes (J) J-Codes are a component of the HCFA Common Procedure Coding System (HCPCS). J-Codes are designed to bill for drugs that are administered in the provider's office, clinic or home health agency either injected subcutaneously, intramuscularly, or intravenously as well selected orally administered chemotherapeutic agents. The J-Code reimbursement only covers the cost of the medication using HCFA guidelines. Office charges associated with the administration of the medication are billed separately. Not a viable option for services!!!

40 C Codes HCPCS (HCFA Common Procedure Coding System) Ambulatory Surgery Center Codes Designed to reimburse for supplies that are used in addition to APC codes Effective April 2001 S Codes S codes nearly double in number this year as private payers create new codes for reporting supplies and services. National S codes are replacing local codes used by private payers L Codes Many of the changes occur in the L codes, with the specification of "custom fabrication" or "prefabrication with fitting and adjustment" adding clarity to more than 100 codes. W, Q Temporary national codes

41 Medical Coding Models Prospective Payment System (PPS) Product & Service Facility (Clustered) Ambulatory Payment Codes (APC) Product / Service Hospital Based (Clustered) J-codes (J) Product Focused Current Procedural Terminology (CPT) Contracted Services

42 Current Procedural Terminology (CPT) CPT 2003 Pharmacy needs to identify and embrace the codes that best apply and describe Pharmacy Cognitive Services Which codes apply to us?

43 Current Procedural Terminology CPT 2003: Standard American Medical Association's (AMA) CPTs - the official industry CPT TM code books. Many of the changes you've anticipated from the CPT-5 project will be seen in CPT 2002, including revamped Category I procedural and service codes and terms, new Category II "Performance Measure" codes, and new Category III "Emerging Technology" codes. New icons refer to the AMA's CPT Changes 2000, 2001, and 2002 books. Don't code without this book which unveils the work of the CPT-5 project!

44 Classification of Evaluation and Management (E/M) Services Current Procedural Terminology (CPT ) is a systematic listing and coding of procedures and services pefformed by physicians. Each procedure or service sia identified with a five-digit code. The use of CPT codes simplifies the reporting of services.

45 Current Procedural Terminology (CPT) Developed in 1966 Published by the AMA A standardized listing of descriptive terms and codes CPT codes simplify the reporting of services Description of medical, surgical and diagnostic services Nationwide communications between providers and payers Universal Coding for services Required for claims processing Primary & secondary code levels 1992 marked the addition of E/M cognitive service codes

46 Classification of Evaluation and Management (E/M) Services Section Numbers Evaluation and Management to Anesthesiology to 01999, to Surgery to Radiology to Pathology and Laboratory to Medicine to 99199, to 99600

47 CPT Coding Evaluation and Management (E&M) Designed for cognitive healthcare services Used by allied healthcare providers Cognitive Service v. Consultation Statement of Medical Necessity codes to support all of the types of services Miscellaneous codes from other sections

48 Table 1 Categories and Subcategories Category/Subcategory Code Office or Other Outpatient Service New Patient Establish Patient Hospital Observation DC Services Hospital Observation Services Hospital Observation or Inpatient Care Hospital Inpatient Services Initial Hospital Care Subsequent Hospital Care Hospital Discharge Services Consultations Office Consultations Initial Inpatient Consultations Follow-up Inpatient Consultations Confirmatory Consultations Emergency Department Services Pediatric (Transport) Category/Subcategory Code Critical Care Services Adult (over 24 months) Pediatric Neonatal Intensive Care (Low Birth Weight) Nursing Facility Services Comprehensive Nursing Facility Assessments Subsequent Nursing Care Nursing Facility DC Service Domiciliary, Rest Home or Custodial New Patient Established Patient Home Services New Patient Established Patient

49 Table 1 Categories and Subcategories Category/Subcategory Code Prolonged Services With direct patient contact Without direct patient contact Standby Services Case Management Services Team Conference Telephone Calls Care Plan Oversight Services Preventative Medicine Services New Patient Established Patient Individual Counseling Group Counseling Other Newborn Care Special E/M Services Other E/M Services 99499

50 CPT & Relative Values Index (RVI) 99201? With one of the industry's largest databases and patented methodologies, Medicode provides you with the best data. Our data files save you time and increase accuracy. No more updating one code at a time, just load the data file into a spreadsheet, database, or other application capable of reading text files.

51 Classification of Evaluation and Management (E/M) Services New and Established Patient Chief Complaint Concurrent Care Counseling Family History History of Present Illness Levels of E/M Services (Low to High) Nature of Presenting Problem Past History System Review Time

52 Classification of Evaluation and Management (E/M) Services New Patient Is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. Established Patient Is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

53 Classification of Evaluation and Management (E/M) Services New and Established Patient Chief Complaint Concurrent Care Counseling Family History History of Present Illness Levels of E/M Services (Low to High) Nature of Presenting Problem Past History System Review Time

54 Classification of Evaluation and Management (E/M) Services Chief Complaint A concise statement describing the symptom, problem, condition, diagnosis or other factor that is the reason for the encounter, usually stated in the patient s words.

55 Classification of Evaluation and Management (E/M) Services New and Established Patient Chief Complaint Concurrent Care Counseling Family History History of Present Illness Levels of E/M Services (Low to High) Nature of Presenting Problem Past History System Review Time

56 Classification of Evaluation and Management (E/M) Services Concurrent Care Is the provision of similar services, eg, hospital visits, to the same patient by more than one physician on the same day.

57 Classification of Evaluation and Management (E/M) Services New and Established Patient Chief Complaint Concurrent Care Counseling Family History History of Present Illness Levels of E/M Services (Low to High) Nature of Presenting Problem Past History System Review Time

58 Classification of Evaluation and Management (E/M) Services Counseling Counseling is a discussion with a patient and/or family concerning one or more of the following areas: Diagnostic results, impressions, and/or recommended diagnostic studies Prognosis Risk of benefits and management (treatment) options Instructions for management (treatment) options

59 Classification of Evaluation and Management (E/M) Services New and Established Patient Chief Complaint Concurrent Care Counseling Family History History of Present Illness Levels of E/M Services (Low to High) Nature of Presenting Problem Past History System Review Time

60 Classification of Evaluation and Management (E/M) Services Family History A review of medical events in the patient s family that includes significant information about: Health status or cause of death of parents, siblings, and children Specific diseases related to problems identified in the Chief Complaint or history of present illness, and/or system review Diseases of family members which may be heredity or place the patients at risk

61 Classification of Evaluation and Management (E/M) Services New and Established Patient Chief Complaint Concurrent Care Counseling Family History History of Present Illness Levels of E/M Services (Low to High) Nature of Presenting Problem Past History System Review Time

62 Classification of Evaluation and Management (E/M) Services History of Present Illness Chronologic description of the development of the patient s present illness from the first sign to the present.

63 Classification of Evaluation and Management (E/M) Services New and Established Patient Chief Complaint Concurrent Care Counseling Family History History of Present Illness Levels of E/M Services (Low to High) Nature of Presenting Problem Past History System Review Time

64 Classification of Evaluation and Management (E/M) Services Levels of E/M Services (3-5 levels per category) 1. History 2. Examination 3. Medical decision making 4. Counseling 5. Coordination of care 6. Nature of presenting problem 7. Time Key Factors

65 Classification of Evaluation and Management (E/M) Services New and Established Patient Chief Complaint Concurrent Care Counseling Family History History of Present Illness Levels of E/M Services (Low to High) Nature of Presenting Problem Past History System Review Time

66 Classification of Evaluation and Management (E/M) Services Nature of Presenting Problem Minimal Self-limited or minor Low severity Moderate severity High severity Morbidity Mortality Functional Impairment

67 Level of History Type Chief Complaint Hx of Illness System Review Focused * Brief - Expanded * Brief Pertinent Detailed * Extended Extended Comprehensive * Extended Extended

68 Level of Examination Type Description Focused Limited Body area or organ system Expanded Detailed Comprehensive Affected area/system and other asymptomatic or related organ systems Extended exam of affected area(s)/system(s) and other related organ system(s) Complete single system specialty or multispecialty examination

69 Level of Medical Decision Making Type # Dx or TX Options Amount and/or Complexity Risk of Complications Straightforward * Brief - Low Complexity * Brief Pertinent Moderate Complexity * Extended Extended High Complexity * Extended Extended

70 Classification of Evaluation and Management (E/M) Services New and Established Patient Chief Complaint Concurrent Care Counseling Family History History of Present Illness Levels of E/M Services (Low to High) Nature of Presenting Problem Past History System Review Time

71 Classification of Evaluation and Management (E/M) Services Key Concept When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then TIME may be considered the key or controlling factor to qualify for a particular level of E/M services. The extent and of counseling and/or coordination of care must be documented in the medical record.

72 Classification of Evaluation and Management (E/M) Services Level of Service Determination - 1. History 2. Examination 3. Medical decision making 4. Counseling 5. Coordination of care 6. Nature of presenting problem 7. Time Top 3 criteria

73 Classification of Evaluation and Management (E/M) Services Time Time was an implicit value prior to E/M in 1992 Time is now an explicit value with regards to services Time is referred to in averages or ranges Intra-service time vs. Total time Types of time Face-to-Face Non Face-to-Face

74 Classification of Evaluation and Management (E/M) Services Face-to-Face Time Time performing the tasks of the service counseling the patient obtaining history examination counseling the patient Time before and after the face-to-face reviewing records and tests arranging further services written and telephone contact (reports)

75 Classification of Evaluation and Management (E/M) Services Unit/Floor Face-to-Face Time Time spent present on the patient s hospital unit and at the bedside rendering services for a patient. Time with chart, nursing staff, writes notes, and communicates Time in related hospital departments (radiology, lab, etc.)

76 Classification of Evaluation and Management (E/M) Services Special Report ( Unlisted Service ) An unlisted service or one that is unusual, variable, or new may require a special report demonstrating the medical appropriateness of the service. Pertinent information should include an adequate definition or description of the nature, extent, and equipment necessary to provide the service. Additional information should address the complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, and follow-up care.

77 Case Study: Pediatric Pharmacokinetics Service New consult of 6 year old female (Dx: Cystic Fibrosis) Day three of admission in hospital Order for service to calculate dose and monitor levels Meds = Gentamicin and Ceftazidime IV Microbiology reports pending Changing from prior antibiotics to new regimen

78 Classification of Evaluation and Management (E/M) Services Inpatient High Low New Established Observation Discharge

79 Classification of Evaluation and Management (E/M) Services Outpatient New Established High Low

80 Classification of Evaluation and Management (E/M) Services Long Term Care (Nursing Facility Care) Comprehensive Assessments Subsequent Care Discharge Services Nursing Facility Care Skilled Nursing Facilities (SNF s) Intermediate Care Facilities (ICF s) Long Term Care (LTC) NOTE: These apply to new and established patients

81 Classification of Evaluation and Management (E/M) Services Patient Assessment: Comprehensive, accurate, standardized and reproducible assessments of each resident s functional capacity. Resident Assessment Instruments (RAI s) Minimum Data Set (MDS) Resident Assessment Protocols (RAPs)

82 Comprehensive Nursing Facility Assessment (new or established): Low Level Evaluation and management of a new or established patient involving an annual nursing facility assessment which requires these three key components: a detained interval history a comprehensive examination; and medical decision making that is straightforward or of low complexity Example from CPT Manual: Counseling and/or coordination of care with others providers or agencies are provided consistent with the nature of the problems(s) and the Patient s and/or family s needs.

83 Establishing a Clinical Billing Relationship Define your service Identify the appropriate CPT code(s) Determine regional CPT ranges for respective codes Interview other practitioners regarding response to codes Apply for privileges to practice in respective setting Could be either review and written authorization Could be outcome of a service contract Have patients sign a authorization to treat and bill consent Document service provided and submit HCFA 1500 Form for claim

84 Medical Coding Models Prospective Payment System (PPS) Product & Service Facility (Clustered) Ambulatory Payment Codes (APC) Product / Service Hospital Based (Clustered) J-codes (J) Product Focused Current Procedural Terminology (CPT) SERVICES! Contracted Services

85 Contracted Pharmacy Services Hospitals Long Term Care Facilities Home Health Care Employer Groups Physicians / Multi-specialty Medical Groups Managed Care Plans Indigent Healthcare Plans Clinical Trials Attorneys (Expert Testimony) Hospice Government

86 Types of Contracts: Contracted Pharmacy Services Fee-for-service (rate schedule) CPT Codes or defined list of services Project-based budget Mutually agreed rated for entire project Performance incentives Capitated Rate Schedule Typically for primary care providers to control utilization Specialist are often fee-for-service Risk-based Contract (shared risk/reward) We don t control the variable We can t control compliance or contracting

87 Managed Care Organization Consulting Models NCQA accreditation outcome study Focus on assessment of outcomes around warfarin therapy Outcomes demonstrated need for therapeutic drug monitoring services Develop referral opportunities and mechanism ongoing payment

88 Managed Care Organization Consulting Models Provide analysis of pharmacy cost and utilization trends Assess patient utilization patterns Impact physician prescribing behaviors Hospitalist teams (clinical pharmacist) Out sourcing clinical services Out sourcing of entire department Flat fee for services

89 Employer Group Consulting Models Insurance Costs Containment Improved Productivity Impact on Bottom Line Reduced Risk Management Liabilities Improved Employee Satisfaction

90 Hospital Consulting Models HIMS Round on daily basis Provide discharge counseling Supported by MCO, PM, and HIMS MD & RPh comprehensive team model Assess in therapeutic drug monitoring and selection

91 Hospital Consulting Models Lacking personnel to provide DUE, staff development, medical and nursing staff education, and TDM Targeted focused programs addressing drug costs and appropriate utilization Fee flat monthly fee and risk with ancillary funding from PM

92 Government Consulting Models Indigent Healthcare Plan Medicare / Medicaid Community Health Centers School Boards (Nurses) Health Department Jails / Prisons

93 Clinical Trials Consulting Models Phase I-IV Human Phase Inpatient & Outpatient Multi-specialty Collaborative practice approach Pharmaceutical Co, CRO s, SMO s, Networks Increased interest in long term care

94 Legal Consulting Models Expert witness Pharmacology & Toxicology Criminal vs. Civil Advertising Hourly Billing Rate Mal Practice, DUI, ADR, Dispensing, Murder

95 Medical Coding Models Prospective Payment System (PPS) Product & Service Facility (Clustered) Ambulatory Payment Codes (APC) Product / Service Hospital Based (Clustered) J-codes (J) Product Focused Current Procedural Terminology (CPT) SERVICES! Contracted Services SERVICES!

96 Superbills Initial trigger for claims processing Critical information of HCFA form Developed based on your own practice Comprehensive summary of services Expedites billing and QA process

97 Superbill Process Paper (customized for your practice) Paper (commercial printed) Software (medical billing or charting) Laptop Palm-based application (cradle or wireless)?

98 Superbills HCFA 1500

99 Strategies for Reimbursement Traditional facility contracts Fee-for-service model Collaborative practice models Insurance Managed Care Plans Other

100 Components Background documentation Treatment plan/algorithm Reporting formats/forms Marketing plans Referral networks Billing & accounting systems

101 Marketing and Stimulating Referrals Increase awareness of clinical services Active in local medical education Professional organizations Develop a marketing plan

102 Key Components of a Successful Collaborative Practice Approach Effective Communication Defined Roles & Responsibilities Define the rational for involvement in terms of benefits to patients, practitioners, and payers

103 Benefits of a Collaborative Practice Approach Improved patient access Utilization of your skills and services Enhanced quality of patient care Expanded reimbursement opportunities Reduced liability

104 Collaborative Practice Perspectives Pharmacists Physician Patient Facility Payer

105 Collaborative Practice Perspectives Interdisciplinary Patient Care Roles and Responsibilities Physician Pharmacist Medical history Physical assessment Diagnosis Patient / disease education Clinical monitoring / management Disease management Medication history Medication assessment Guidance on product selection Patient / medication education Treatment compliance & outcome assessment Pharmacologic management

106 Collaborative Drug Therapy Review Physician Patient Assessment Drug Selection Treatment Plans Monitoring & Evaluation Clinical Pharmacist

107 Collaborative Practice Agreements Short and focused Logistics of delivering your services Methods of communicating results and decisions Delineate mutual goals and liabilities Develop standardized pathways (when possible) Financial Referral terms Three way agreement (physician, pharmacists, patient)

108 Disease Management Models Need and role promote understanding and teach coping strategies conduct compliance education & monitoring track & trend specific patient outcome variables Promote physician intervention Driven by diversity of payer mix Target patients who cycle between care settings Requires marketing and clinical expertise Initiative focus is collaboration, education, and intervention

109 Disease Management Models Determine local needs & opportunities Identify plan demographics (patients & plan type) Develop Objectives Scope of Services Physician, Patient, and Plan Marketing Materials Determine Fee Structure

110 Disease Management Models Congestive Heart Failure (CHF) Depression Polypharmacy Diabetes Arthritis Pneumonia & Respiratory Tract Infections Anticoagulation

111 Group Practice Model: If this really works now, than what can the future look like???

112 Are You Really Ready to Change? Who is going to get paid for the services? The pharmacy provider (employer) The home You How are you going to balance your time? Where do your loyalties fall? Patient Physicians Your practice development plans Your Employer s Agenda

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114 Tools and Resources Ingenix CPT Coding Manuals HCPCS APC Coding Tables

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116 Software Applications Pharmacy software? Retail dispensing programs (product & dispensing focused) Hospital Pharmacy Programs (product & dispensing focused) Long-term care (product & dispensing focused) Outcome software (intervention tracking lacking on billing) Medical office software? Office management focused Medical records management Patient scheduling Electronic charting Billing often an optional product or interface oriented? Medical Billing software? Accustomed to converting service descriptions into billing codes Utilize established billing forms such as HCFA 1500 We need to create a blend

117 The Future of Reimbursement for Clinical Pharmacy Services Ability to get reimbursed today Can t get paid if you don t initiate billing process Nothing wrong with getting paid Necessitates modifying your current practice model Increased recognition from HCFA and Industry Momentum of HIPPA Regulations CMS Provider number Consultant first..billing Practitioner later! Medication error rates and shortages driving the need

118 Questions & Answers: How do you get started? What will my employer say? What do I use as benchmarks or templates? Can I really make a living? What are my biggest hurdles from stopping me today? Has anyone ever done this and survived?

119 Daniel E. Buffington, PharmD, MBA Practice Director 6285 E. Fowler Ave, Tampa, FL Office Fax