Payments and Fee-Structure associated with Medication Therapy Management Services

Outlined in the Medicare Prescription Drug, Improvement and Modernization Act of 2003, the new reimbursement opportunity allows pharmacists to bill the federal government for meting out counseling sessions to certain covered patients with regards to their prescription drugs. The legislation, effected in 2006, mandates that all insurance providers, offering a Medicare Prescription Drug Plan, must render Medication Therapy Management Services to eligible candidates and compensate licensed and qualified health care professionals for conducting counseling sessions for the patients.

According to the Centers for Medicare and Medicaid Services (CMS), the fee, reimbursed by plan sponsors, must justify the time and resources that the relevant health care provider has invested in the patient, while providing Medication Therapy Management services. Many questions, in relation to the payment and fee-structure of a Medication Therapy Management( MTM ) program, still remain unasked, unsolved and thus, invite speculations.

The reimbursement rates and criteria vary with specific prescription drug-plans and hence, are unique. Although CMS does not interfere with regards to the dispensing fees that pharmacies manage to secure from plan sponsors, it requires sponsors to give a comprehensive explanation of the fee structures of their MTM programs. Only pharmacists, providing services that are validated by the relevant state’s “scope of practice”, are entitled to MTM reimbursements. Pharmacists, in order to practice, have to abide by the rules and regulations, issued by the state.

Drug plans are still trying to figure out proper ways to compensate pharmacists, but most of them follow the variants of fee-for-service model, paying fees for fixed services either directly to the pharmacist or to the organization, he/she works in behalf of. A typical reimbursement schedule covers comprehensive medication reviews, sessions with the primary health care provider, patient compliance and over-the-counter medication consultations, refusal from the end of the prescriber and patient’s education as well as thorough monitoring.

Counseling sessions can be arranged on the request of any of the patient, his caregiver, plan sponsor, pharmacist and/or prescriber. Any person, covered by Medicare, can avail of these sessions, as and when required. Even if a patient struggles with his expensive prescription drugs, if he has not signed up for the Medicare Part D benefit, MTM will not apply to him. Pharmacists can claim reimbursements for their designated services, only when they sign an agreement with the relevant drug plan or Medicare Advantage Plan in their area.

Lately, the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel has recognized three billing codes- Code 0115T, Code 0116T and Code +0117T- for pharmacists in order to bill third-party payers, while conducting Medication Therapy Management services face-to-face between a pharmacist and a patient. PSTAC, primarily founded to enhance the overall coding infrastructure, has created a Place of Service (POS Code 01) code, in addition to other POS codes (Code 11, “Office,” or 99, “Other Place of Service”), efficiently harmonizing pharmacists and their professional services into the traditional medical services billing model. Pharmacists can easily avail of this code in order to bill for services in a pharmacy setting.

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