Understanding Independent Pharmacists and the Affordable Care Act



Till very recently pharmacists were seen as dispensing medication, counselling patients on use of prescription and over the counter medication, advising patients about general health topics, and often serving as a liaison between patients and the complex insurance regulatory system.

However, with the Patient protection and Affordable Care Act (PPACA) of 2010, popularly known as Obama Care, whose goal is to improve healthcare quality, reduce healthcare costs and expand health insurance coverage, the pharmacy industry underwent many changes. Pharmacists have been seen as key stakeholders in improving patient care, quality and outcomes.

Additionally, the PPACA exempted many independent community pharmacists from a Medicare rule requiring all sellers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) to become accredited. The consequence of this was that it allowed pharmacies generating less than 5 percent of revenues from DMEPOS sales to continue meeting patients’ critical health needs without incurring the cost of complying with duplicative regulations.

Further, with the launch of Accountable Care Organizations, medical homes and other alternative patient care models have created opportunities for pharmacists to get involved in these emerging care models. Physicians are increasingly recognizing that including pharmacists on the health care team is valuable for services such as managing complex medication therapies, providing patient education, and reducing medication costs and preventing problems with drug therapy. The ACA has recognized the value of pharmacists to provide cognitive services as part of patients’ overall healthcare.

Data from Sageworks, a financial information company, has shown that sales among privately held pharmacies and drug stores rose from 3.1 percent in 2013 to 6.3 percent in 2014, nearly double the sales growth. These figures testify to the growing opportunities that have opened up since the introduction of the ACA.

Although, Medicare Part B reimburses physician and specific non-physician health care professionals for medically necessary and preventative health care services, but rarely reimburses pharmacists for health care services, for face-to-face patient consultations, the American Medical Association (AMA) provides 3 billing codes whereby Medicare is now required to pay for these very services for eligible patients, medically billed under any of these AMA codes.

Due to the new rules & regulations that are now pushing for electronic processes and workflows, many drug stores have implemented electronic prescribing software that allows them to fill prescriptions more efficiently and to better plan inventory. Technology and new services also have helped stores utilize pharmacy staff more efficiently, for example, to handle automatic refills during hours when foot traffic in the stores is slower. Technology has greatly enhanced pharmacy billing, aiding in better reimbursement.

Thus, the Affordable Care Act has led to the opening up of new revenue streams for pharmacies and drug stores, since many states have implemented expanded Medicaid coverage. It has given independent pharmacists the opportunity to not only provide additional care to the patients but also help increase their profit margins and thus create an effective Revenue Cycle Management (RCM) process.

This entry was posted in Pharmacy, Pharmacy Billing Services, Pharmavy Billing Services, Revenue Cycle Management (RCM) and tagged , , . Bookmark the permalink.


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