An Overlooked Way for IHS/Tribal Pharmacies to Get Paid for MTM

As an IHS/tribal pharmacy, are you looking for ways to do more medication therapy management (MTM) AND create new revenue to support these clinical services?

If you have Medicaid patients coming to your pharmacy, this is something you can look at taking advantage of if your pharmacy isn’t already doing this. For a number of years, IHS has signed an agreement with CMS.  This agreement says that when there are clients (patients) who need to be seen through state Medicaid programs and are seen at tribal or federal clinics, instead of going through complicated billing procedures, the following can happen:  if a person who’s Medicaid eligible comes to the tribal facility, CMS would pay the clinic/hospital to cover the cost of that visit on a fixed rate.

What this can mean for the pharmacy: Pharmacy can get reimbursed around $300 (fixed rate) per medication therapy management visit.

How:  If a patient comes in on a Mon & sees a healthcare provider (ie, primary care provider) named under the CMS contract, the primary care provider can bill a flat fee for that visit as per the contract (ie, around $300).  If the primary care provider refers the patient to a pharmacist who can see the patient for medication therapy management (or other clinical encounter, ie: smoking cessation, etc) on a different day (ie, Wednesday), the pharmacist clinical visit can also be billed to CMS for that same flat fee (ie, $300).

NOTE:  In some states, pharmacists are noted as a direct provider on the CMS/IHS contract. Pharmacist may see patients for MTM services without a referral.  

In other states, pharmacists are not noted as a direct provider under the contract. If pharmacists are not specifically excluded from the contract, pharmacies may interpret the federal register.  Pharmacists can consider acting as an agent of the physician.  Pharmacist is referred a patient by a medical provider, provides the care & submits a report in EHR for example, noting to the referring physician the SOAP note & outcomes of visit, and include the referring physician as the provider of record for CMS.

What it is: This is a scheduled visit from a referral from a primary care physician (or direct appointment pharmacist books with patient) where a pharmacist offers medication therapy management for a patient.

What it is not: This is not just a visit for dispensing prescriptions.  Also, the visit must be medically justified.

What can be possible: Pharmacy can actually spend time with patients and offer more clinical intervention.  This can contribute to saving overall healthcare costs. The pharmacy can get reimbursed for providing these MTM services. Pharmacy can also justify hiring additional people to take care of people who are chronically ill.  Especially in areas where pharmacy services are not currently being offered to the tribe, this can be an opportunity to make MTM services available to your tribal or eligible members. Offering medication dispensing services is not required.

In the lower 48 states, the reimbursement is over $300.  In AK, it’s over $400.
Just 3 MTM visits in a day can cover pharmacist salary plus much more.

Where to look into this more: The contract is in the federal register which you can find online here.  It gives general guidelines & itemizes lower 48 & AK contract rates.

From an interview with Don Downing. Don Downing, RPh helped start up the nation’s first self-determination tribal clinic. He has 38 years of experience in tribal healthcare work and continues to work with a number of tribes to implement clinical pharmacy services.  He is a professor at the University of Washington School of Pharmacy.

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About Chen Yen, PharmD

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