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Reviewing Reimbursement Statutes, Regulations for Pharmacist-Provided Health Care Services

November 24, 2020

Differing reimbursement statutes and regulations between states results in significant variability in compensated services and reimbursement, according to recently published data in the Journal of the American Pharmacists Association.

In an effort to better understand these differences and potential ramifications, Elaine Nguyen, PharmD, MPH, assistant professor, College of Pharmacy, Idaho State University, Pocatello, ID, and colleagues, conducted a multistate review of existing statutes and regulations for pharmacist-reimbursement in Alaska, California, Idaho, New Mexico, Oregon, and Washington. Four of these states currently allow for direct reimbursement of pharmacist-provided health services and 2 states are in the process of allowing.

“Washington requires commercial health plans to credential and privilege pharmacists as health care providers deeming reimbursement and coverage disparities among providers as compensation discrimination,” noted Dr Nguyen and colleagues.

According to the findings, insurers in Oregon are not required to provide payment, but instead, pharmacists are required to contract and credential with each individual insurer, without the mandate for payment.

“In California, pharmacists receive 85% of the established fee schedule that physicians receive for equivalent services, and payment is issued to the pharmacy, not the individual pharmacist,” explained the researchers. “California and New Mexico both only allow specified pharmacies or pharmacists to bill (advanced credentials or a tiered licensing model).”

Alternatively, in Alaska, “scope and payer regulations align to allow compensation for covered services; however, insurance credentialing portals are not configured to enroll pharmacists as billing providers.”

The researchers went on to explain that as of May 2020, “pharmacists were added as nonphysician ordering, referring, and prescribing providers in the Idaho Medicaid basic plan regulations, and licensed pharmacists with national provider identification numbers were auto-enrolled.”

Based on the high variability between states, in pharmacy, public, and private insurance, the researchers explained that the approaches could result in significant variability in compensated services and reimbursement. They suggest and intentional alignment of these statutes, regulations, and scope of practice, in order to support reimbursement and sustainability of services.

—Edan Stanley

Nyugen E, Walker K, Adams JL, Wadsworth T, Robinson R. Reimbursement for pharmacist-provided health care services: A multistate review [published online October 15, 2020]. J Am Pharm Assoc.

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