Pharmacy Clinical Services: Don’t Miss Out
As patients look for ways to obtain healthcare in more convenient and lower-cost settings, new opportunities are emerging for retail pharmacies to help meet patient needs. Many pharmacies already are recognized as cost-efficient channels for expanding public access to vaccinations, disease management, medication management, and other clinical services.
In fact, the business case for bringing clinical services in-house is an easy one for pharmacies to make because all stakeholders win: pharmacies, payers, providers and patients. In-store clinical services are becoming an increasingly viable option for pharmacies, especially as the industry continues to embrace an elevated clinical role for pharmacists.
With payers expected to drive further expansion of pharmacy-rendered clinical care—and new infrastructures to support the addition of these revenue streams—retail pharmacies simply can’t overlook the potential benefits.
Taking Hold of Clinical Services
The concept of adding clinical services to the pharmacy is not new. Medicare Part B has allowed pharmacies to provide immunizations since the early 2000’s. Recognizing the value, commercial payers have pushed for more clinical services in retail pharmacies—which in turn has made them more practical and attractive.
Yet until recently, infrastructure limitations have challenged retail pharmacies’ ability to appropriately bill for clinical services. Since pharmacy information systems typically only support billing a patient’s pharmacy benefit, pharmacies have had to resort to manual processes to bill for clinical services through patients’ medical benefits.
Fortunately, industry advances now allow retail pharmacies to maintain their existing infrastructures while integrating with solutions to bill medical benefits. Here’s what happens:
A retail pharmacy submits a claim for clinical services through a pharmacy benefit platform. The claim is edited and pre-adjudicated. Once approved, data from the claim is translated into a medical benefits claim and submitted via the third party solution. Remittance advice is then sent back to the pharmacy so the information can be absorbed into appropriate accounts receivable systems.
This kind of technology support allows retail pharmacies to build profitable immunization programs, such as offering flu, pneumonia and shingles vaccines. It can also enable chronic disease management and preventative care services.
As helpful as technology can be, however, another part of getting an initiative off the ground is understanding the regional market. Pharmacies need to take a progressive approach to explore potential relationships and contract opportunities with health plans, employers and risk-bearing entities, such as accountable care organizations.
A Positive Future Outlook
Clinical services offerings within retail pharmacies are still in their infancy. However, with the billing workflow issue solved, pharmacies face fewer obstacles to bringing this revenue-generating business line in-house.
Large national chains, as well as many regional retail pharmacies, already work diligently to engage patients on a higher clinical level. Some states are also considering the potential benefits of elevating the role of pharmacists to provider status. Pharmacies that take steps now to deploy the best workflow infrastructures and develop key relationships within their local and regional networks stand to gain the most as the future of healthcare delivery unfolds.
Todd Evans is VP of Product Management, Networks at Change Healthcare.