Transcript Slides - Washington State Pharmacy Association

Reaching a
Tipping Point?
Pharmacist Provider Status
Efforts in Washington State
An Overview of SB5557
“The tipping point is that magic
moment when an idea, trend, or social
behavior crosses a threshold, tips, and
spreads like wildfire.”
―Malcolm Gladwell,
The Tipping Point: How Little Things Can Make a Big Difference
Provider Status Triad
1.
2.
3.
Provider designation
Scope of practice
Recognition by payers
“Provider Status” Designation
 Pharmacists
are healthcare providers in
Washington State Law i.e. “Provider
Designation”


Incorporated in appropriate practitioner and
healthcare provider definitions
In 2013, amended the Legend Drug Act to include
pharmacists as prescribers- Legislation HB 1182 passed
and signed by Governor.
Scope of Practice
 In
1979, Definition of Pharmacy Practice
“Practice Act”
 RCW 18.64.011 includes:
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“initiating and modifying drug therapy
through written protocols and guidelines”
CDTA
“administering” of drugs and devices
“monitoring of drug therapy and use”
Collaborative Drug Therapy Agreements
(CDTA) per WAC 246-863-100

These agreements shall include:

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Practitioner(s) authorized to prescribe and pharmacist(s).
A time period not to exceed 2 years.
Type(s) of prescriptive authority decisions pharmacist(s) are
authorized to make, including:
Types of diseases, drugs, or drug categories involved, and
the type of prescriptive authority activity authorized in each
case.
 Procedures, decision criteria, or plan pharmacist(s) are to
follow when making therapeutic decisions.


Activities pharmacist(s) must follow in the course of
exercising prescriptive authority
documentation of decisions made,
 a plan for communication or feedback to the authorizing
practitioner concerning specific decisions made.

Monitoring of Drug Therapy and
Use (WAC 246-863-110)
 Collecting
and reviewing patient drug use
histories;
 Measuring and reviewing routine patient vital
signs
 Ordering and evaluating the results of lab tests
relating to drug therapy
 blood
chemistries and cell counts,
 drug levels in blood, urine, tissue or other body fluids,
 and culture and sensitivity tests
 when performed in accordance with policies and
procedures or protocols applicable to the practice
setting
Recognition by Payers
 Prior
to SB 5557
Limited to PHARMACY contracts with PBM’s for
“professional services” provided during dispensing
of a medication
OR
 “Incident to” or “Facility Only” billing for services in
concert with a physician in certain settings.
OR
 Individual specifically identified pharmacist
provided services such as vaccine administration,
MTM etc.

“Every Category of Provider” Law
 In
1995, RCW 48.43.045(1) requires health plans in
Washington to include access to every type or
“every category” of licensed medical provider to
provide health care services to care for conditions
included in the basic health plan.
 Pursuant
to WAC 284-43-205, “health carriers shall
not exclude any category of provider licensed by
the State of Washington who provide health care
services or care within the scope of their practice
for conditions covered by basic health plan (BPH)
services as defined by RCW 48.43.005(4)
“Every Category of Provider” Law
 Initially,
the law was interpreted by Insurance
Commissioner Kreidler’s office to NOT include
pharmacist provided services therefore it was
NOT enforced.
 We worked with OIC over multiple years to
educate and request enforcement of law.
 The Washington State Joint Select Committee of
Health Reform Implementation led by Senator
Linda Evans Parlette requested an Attorney
General informal opinion in November 2012.
“Every Category of Provider” Law

In January 2013, WA State AG Ferguson’s office
provided the informal opinion confirming:
“Pharmacists are health care providers and must be
compensated for services included in the basic
health plan that are within the scope of the
pharmacist’s practice if the pharmacist agrees to
abide by stated standards related to cost
containment, management, and clinically
efficacious health services.”

The informal opinion was not a silver bullet, but
reinforced our long held belief that payers must
credential, and contract with pharmacists for services.
Legislative Fix
 Investigated
why the Every Category of
Provider law had not been enforced by the
Office of the Insurance Commission.
 Identified
loophole in the law that allowed
health plans to justify not including
pharmacists in their provider networks.
 We
worked with OIC to address this loophole.
 Resulted
a legislative fix: SB 5557
Legislative History
 Introduced




by Senator Linda Evans Parlette (R-12)
March 2nd, Senate pass legislation.
April 14th, House pass legislation with changes.
April 16th, Senate agrees to House changes.
May 11th, Governor signed bill into law.
Legislative Intent
 Fixes
a loophole in Every Category Provider law.
 Recognizes pharmacists as patient care providers
within scope of practice.
 Encourages
greater
collaboration
among
pharmacists, physicians, and other providers.
 Changes perception of pharmacy profession.
 Increases patient access to care.
 First state to pass comprehensive provider status
legislation using this approach.
 Tactic can immediately be used by other states
with “every category of provider” type laws.
SB 5557 Highlights:
Pharmacists as Patient Care Providers
 Health
plans recognize pharmacists as patient
care providers for covered benefits.

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Health plans required to include adequate number
of pharmacists in their participating provider
networks.
Includes services covered as essential health
benefits requirements.
Inclusion of pharmacies in health plans’ drug
benefit networks do not satisfy new requirements.
In short, pharmacists will be treated the same as
other providers.
SB 5557 Highlights:
Tiered Implementation Dates
2016
Health carriers who
delegates credentialing to
health facilities must accept
pharmacists employed or
contracted by those facilities
in their participating provider
networks.
Health facilities reimbursed
for covered services based
on negotiated contracts.
2017
Health carriers must accept
pharmacists in their
participating provider
networks.
SB 5557 Misconceptions
FALSE
Patients can skip physicians completely and
FALSE
Changes pharmacists’ scope of practice.
FALSE
Health carriers must include ALL pharmacists in
their participating provider networks.
FALSE
Pharmacists’
provider
status
will
change
immediately after the legislation is signed into law.
FALSE
receive medical services from pharmacists.
Health carriers must cover ALL services provided
by pharmacists in their participating provider
networks.
SB 5557 Highlights:
Advisory Committee Process
 OIC
designated a lead organization.
 Lead organization formed Advisory Committee.
 Advisory Committee developed best practice
recommendations for standards on credentialing,
privileging, billing and payment
 Advisory Committee provided best practice
recommendations to OIC and DOH by December
1, 2015.
 If needed, OIC and DOH develops rules based on
recommendations.
SB 5557 Highlights:
Advisory Committee Participants
 Representative(s)






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
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from:
Lead Organization (OneHealthPort).
State agencies (OIC and DOH).
Trade associations (WSPA, WSMA, and WSHA).
Health carriers (Premera and Regence).
Health care system that coordinates care and coverage
(Group Health).
A hospital with internal credentialing process.
Health facilities with pharmacists providing medical services
(one clinic and one community pharmacy).
Pharmacy school within the state (UW or WSU).
PBM.
Others selected by OIC
The Road Ahead
Legislation
Signed into law by May 2015
Advisory Committee
Begin meeting during summer 2015
Deliverables to OIC
Recommendations due by December 2015
and rules, if needed, in 2016
Implementation
Health facilities with credentialing
agreements with health carriers in 2016 and
full compliance in 2017
Advisory Committee Work
 INTENT:
to ensure that pharmacists will be
regarded as any other provider, in accordance
with relevant state law, as it relates to health plan
billing, processing, and payment of claims for
medical services that are provided.
 SCOPE OF WORK: recommend guidelines for
payment-dependent interactions between
health plans and pharmacists/provider
organizations, i.e. Contracting, Credentialing,
Utilization Review, and
Coding/Billing/Reimbursement.
Advisory Committee Deliverables
Specific deliverables include:
 FAQ
document
 Health Plan Policy Directives document
 Pharmacists and Other Provider Expectations
document
FAQ Document
 Document
reflects industry information, gathered
during a discovery process that offers
understanding and context for the recommended
Policy Directives and Expectations.
Clarifications about SB 5557
 Pharmacist’s scope of practice, licensure
requirements, training, education, and certifications
 Collaborative Drug Therapy Agreements (CDTA)
 Credentialing and Privileging

FAQ Document
 Are
pharmacists primary care providers or specialty
care providers? Are there implications for co-pay?
 What are the different places of service in which a
pharmacist may practice?
 Is a diagnosis required to bill for services?
 What CPT/HCPCS Codes do pharmacists anticipate
billing? How will they be reimbursed?
 What are documentation and coding standards for
medical services?
 What claim forms are used for the billing of medical
services?
 Will Pharmacist bill directly or as “incident to”?
Health Plan Policy Directives
 Identifies
policy conditions/requirements that
health plans will have in place to enable the
billing and appropriate reimbursement of
medical services provided by pharmacists.


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Contracting
Credentialing
Utilization Management
Coding/Billing/Reimbursement
Provider Expectations
 Lists
and briefly describes the expectations
and/or requirements that will need to be met
by pharmacists, other providers, and other
stakeholders in order to operationalize, within
their respective organizations, the
reimbursement of pharmacist-provided
services.
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Applicability
Contracting
Credentialing
Privileging
Utilization Management
Coding/Billing/Reimbursement
Key Issues
Does this legislation require all health plans to
reimburse pharmacists for medical services that they
deliver? NO
 The 5557 legislation only requires Washington State
licensed insured large group, small group,
individual, and family plans to reimburse for
pharmacist provided medical services.
 These reimbursement requirements may not apply
to Federal plans such as Medicare, Tricare, TaftHartley AND to other State plans, e.g. PEBB/Uniform
Medical plans, Washington State Medicaid and
related plans, commercial self-insured plans, etc.
Key Issues
Are pharmacists being regarded as all other
provider types? YES
 The intent of this document is that pharmacists
fall under the “Every Category of Provider” law.
Key Issues
For a given type of provider, e.g. pharmacists,
do the credentialing requirements of a health
plan vary depending upon the services to be
provided by that pharmacist, i.e. is credentialing
service-specific? NO
 Examples
 For
health plans, the defined set of credentials
gathered and verified for a provider, e.g. PA,
ARNP, Pharmacist, to deliver services to that
health plan’s members do not vary based on
the specific services that a provider of that type
delivers in the course of their work.


Example
For organizations that are both a provider
organization AND a health plan i.e. provide patient
care and take on financial risk for providing care


the defined set of credentials gathered and verified
for a provider, e.g. PA, ARNP, Pharmacist, may vary
based on the specific services that a provider of that
type delivers in the course of their work.
Similar to provider organizations, these organizations
have a baseline set of credentials that apply to all
providers of a given type AND they may have
additional training and certification standards
depending upon the services that the provider
delivers.
Key Issues
Might health plans change credentialing requirements
over time for all providers of a given type (including
pharmacists)? YES
 Health plans may, at some point in the future, require
additional certifications and/or advanced training in
order for pharmacists to be credentialed.


They may require advanced certifications for all
pharmacists or may define different types of pharmacists
and vary credentialing requirements by type. This practice
will not be uniquely directed towards pharmacists as health
plans manage all provider types in this manner.
Based upon discussion with stakeholder health plans there
are no intentions, at least for the foreseeable future, to
change credentialing requirements for pharmacists from
those that are outlined in the Policy Directives document.
Key Issues
Are pharmacists required to get a diagnosis from a
medical provider in order to bill a health plan for
preventive care and related services? NO
 Though a diagnosis is ALWAYS required on any/all
claim forms, pharmacists are not required to get
a diagnosis from a medical provider if/when they
are billing for medical services that are not
related to injury or illness.
 Specific ICD10 diagnosis codes (Z series codes)
are available to pharmacists for billing preventive
care and associated services that are not related
to injury or illness.
Out of the Committee’s Scope
 Guidelines
for internal capabilities required of
organizations to perform those interactions are not
the focus of this work.
 Similar to other providers, the capability to interact
with health plans must be in place.
 Business processes/work flows, coding,
education/training, and clinical record
management/billing systems are pre-requisites for
a) submitting claims to health plans for medical services
delivered by pharmacists and
b) appropriately billing and collecting patient costshare.
Peripheral efforts

Preparation of pharmacy professionals
 Education
needs for practicing
pharmacists/technicians, student pharmacists

Establishment, awareness and support of new
processes
 Credentialing,

Privileging, Contracting, Billing
Business Preparation
 Health
information technology
 Workflow/Staffing
 Financial Planning ie cash flow differences
Identified Knowledge Gaps
 Tailoring
and transitioning care to recognition
within the medical benefit coverage
 Inclusion in participating provider networks

Credentialing processes
 Delegated
credentialing
 Direct credentialing

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Privileging Processes
Contracting with Health Plans vs PBMs
Network Adequacy
Identified Knowledge Gaps
continued
Billing processes
 Retrospective
Billing
 Documentation
 Identifying Covered Services
 Coding ICD 10, CPT, HCPCS etc
 Referrals
 Avoidance of Duplication
 Patient Billing: Co-pays/Co-Insurance identification and
collection
 Pre-Auth, Referral and other Pre-Service requirements
 Payment adjustments – take backs
 Audit protection
Identified Knowledge Gaps
continued
Health information technology
 HIE
 Clinical
data sharing
 Electronic
Health Record for Documentation
& Reporting
 Electronic
Medical Record – patient clinical record
 Practice Management Software – scheduling,
billing, business management
Next Steps
 The
WSPA will be working with members and
partners.




Content experts to support advisory committee work
Advocating for appropriate integration of
pharmacists into provider networks
Addressing knowledge gaps
Sharing with colleagues throughout the country
WSPA Implementation Workgroups
 Credentialing
and Privileging
 Billing, Coding, Contracts, Documentation
 Technology and Communication
 Outcomes and Research
Credentialing and Privileging
 Scope

Determine best practices and tools for credentialing
and privileging pharmacists.
 Potential
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Tasks
Develop credential tools or best practices for
pharmacists.
Compare and contrast provider credential
requirements.
Identify and review existing national guidelines.
Provide guidance on privileging pharmacists in
different settings.
Identify gaps in education or training that hinders
obtaining credentials.
Billing, Coding, Contracts, Documentation

Scope


Determine best practices to ensure pharmacists meet billing
and documentation standards, and provide tools to
facilitate the billing of services through contracts with
health plans.
Potential Tasks

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Compile and review list of ICD-10 and CPT/HCPCS codes
pharmacists can use for billing purposes.
Identify gaps in billing codes.
Review existing contracts and develop best practice
resources for pharmacists.
Complexity vs. time-based billing (complexity algorithms).
Provide guidelines on documentation and coding
standards for medical services.
Outcomes and Research
 Scope

Determine the metrics to measure and report quality
and outcomes of using pharmacists in providing
patient care.
 Potential



Tasks
Review national and state quality metrics.
Determine metrics that should be collected.
Develop a strategy for research and publications.
Technology and Communication
 Scope

Determine guidelines to integrate technology in
pharmacy practices to ensure interoperability, billing
and payments, practice management, and
documentation.
 Potential

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
Tasks
Identify technological gaps in pharmacy practices.
Develop best practice resources for technology.
Compile list of vendors that can provide customize or
bundled technological software.
Workgroup Proposed Timelines
 WSPA
Process: Jan. 2016 - Apr. 2016
 WSPA Implementation: May 2016
 Research Outcomes: Future Aim
“Look at the world around you. It may seem
like an immovable, implacable place. It is
not, with the slightest push - in just the right
place - it can be tipped.”
―Malcolm Gladwell,
The Tipping Point: How Little Things Can Make a Big Difference
Our Next Challenge is Adapting…
“Enjoying success requires the ability to
adapt. Only by being open to change will you
have a true opportunity to get the most from
your talent”
-Nolan Ryan
Hall of Fame Baseball Player
Questions?
Jeff Rochon, Pharm.D.
Washington State Pharmacy Association
[email protected]