Billing and Reimbursement for Patient Care Clinical Services Certificate
The Billing and Reimbursement for Patient Care Clinical Services Certificate is intended for pharmacists who are engaged in providing clinical services in a variety of practice settings, and others who are involved in billing for these services. Mary Ann Kliethermes, BS Pharm, PharmD, FAPhA, FCIOM; a recognized leader in reimbursement for pharmacist care services; serves as the editor for this one-of-a-kind, comprehensive resource. Through recorded presentations and readings, this Certificate’s curriculum includes, but is not limited to, the following topics:
- Language of healthcare billing
- Reimbursement models including fee-for-service and value-based care models
- Medicare, Medicaid, and commercial insurance payers
- Rules related to eligibility of healthcare professionals to bill for services
- Collaborative practice agreements
- Medical vs. prescription benefits
- Payer mix
- “Incident to” as a billing mechanism
- Facility fee billing
- Care management services – chronic care, principal care, and transitional care
- Medicare Annual Wellness Visits
- M edicare Diabetes Prevention Program and Diabetes Self-Management Training
- Medication Therapy Management
- Continuous glucose monitoring and home INR monitoring
- Telehealth
- Reimbursement in federally qualified health centers (FQHCs) and rural health clinics (RHCs)
- Pharmacist prescribing and reimbursement opportunities at the state level
- Building the business case for pharmacist patient care clinical services
- O utside opportunities to fund patient care clinical services
- Preparing for successful implementation and growth of services
- Engaging with commercial insurance payers to be reimbursed for patient care clinical services
- Healthcare billing cycle
- Electronic billing
- Managing claims before and after adjudication
- Staying current with billing and reimbursement rules and opportunities
Professional Certificate Requirement
Once a learner has completed the educational curriculum, they will have the opportunity to complete an online comprehensive exam. Once the learner completes the exam (minimum 80% passing rate; unlimited attempts permitted), they will earn the professional certificate.
Accreditation
The American Society of Health-System Pharmacists is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education with Commendation.
Target Audience
This self-guided, online program will provide 22.5 hours of ACPE continuing education for pharmacists, incorporating recorded presentations, readings, and worksheets.
Course Modules
Learning Activity
ACPE Number
Contact Hours
Fundamentals of Healthcare Billing
Healthcare Models of Reimbursement in the US
Billing & Reimbursement Methods and Opportunities for Pharmacist Patient Care Clinical Services
Managing the Business of Pharmacist Patient Care Clinical Services
→ Final Assessment (80%passing score required)
Learning Objectives
Fundamentals of Healthcare Billing
ACPE: 0204-0000-23-824-H04-P
- Summarize the history of billing for healthcare services.
- Justify the need for pharmacist patient care billing using medication-related health statistics.
- Identify the basic elements of a healthcare billing claim.
- Select an appropriate healthcare billing claim based on the services rendered and why, where, and by whom to the services were rendered.
- E xplain the factors considered when determining Medicare reimbursement for medical provider services.
- Define an eligible healthcare provider under federal Medicare rules and regulations.
- Analyze the legal conditions that provide opportunities and/or barriers for reimbursement for pharmacist patient care services in one's state.
- Differentiate between medical and prescription benefits.
- Explain appropriate circumstances for billing medical vs. prescription insurance.
- Compare the advantages and challenges associated with medical and prescription benefits.
- Describe key stakeholders in the billing process and their respective roles.
- Define standard revenue cycle terms.
- Describe different types of audits along with important considerations.
- Develop a resources toolkit to comply with payer-specific rules and regulations for billing and reimbursement for pharmacist-directed services.
Healthcare Models of Reimbursement in the US
ACPE: 0204-0000-23-825-H04-P
- Describe the key elements of fee for service (FFS) payment models.
- Compare fee for service and mixed payment models.
- Explain key factors driving alternative, i.e., value-based, payment models.
- Differentiate alternative/value-based payment models from fee for service models.
- Identify the types of alternative/value-based payment models.
- Describe the integration and value of pharmacists in care teams practicing with alternative/value-based payment models.
- Summarize how performance is measured in alternative/value-based payment models.
- Explain the keys to success for alternative/value-based payment models.
- Identify medical insurance options for special patient populations.
- Evaluate the payer mix for one's organization.
Healthcare Payers
ACPE: 0204-0000-23-826-H04-P
- Explain patient enrollment, coverage, and costs for Medicare Part A and Part B services.
- Assess supplemental medical coverage options for Medicare.
- Compare original Medicare and Medicare Advantage coverage and costs.
- Explain patient enrollment, coverage, and costs for Medicare Part D.
- Evaluate assistance for prescription and medical insurance costs including Medicare Low Income Subsidy, dual eligibility, and Special Needs Plans.
- Explain the role of Medicare administrative contractors (MACs).
- Interpret the Medicare Physician Fee Schedule, Hospital Outpatient Prospective Payment System, and other Medicare rules.
- Compare reimbursement opportunities between a federally qualified health center (FQHC) and a standalone physician practice.
- Explain the role of quality metrics in FQHCs and how performance on quality metrics, such as Uniform Data System (UDS), may impact reimbursement.
- Explain the differences between a rural health clinic and a federally qualified health center.
- Identify fundamental components of the benefit structure of commercial insurance plans.
- Explain the structure of Medicaid programs, including federal requirements.
- D escribe key aspects of healthcare exchanges.
Billing & Reimbursement Methods and Opportunities for Pharmacist Patient Care Clinical Services
ACPE: 0204-0000-23-827-H04-P
- Explain the role of "incident to" as a mechanism for pharmacist-generated revenue.
- Compare and contrast the requirements of facility fee and non-facility fee billing for outpatient services.
- Select the billing codes utilized for office or other outpatient services in the evaluation and management of established patients.
- Identify revenue-generating opportunities for pharmacists participating in the delivery of care management services.
- Evaluate revenue-generating opportunities for pharmacists participating in outpatient procedures.
- Select appropriate billing codes utilized for the monitoring of specific disease states or medications.
- Analyze billing and reimbursement opportunities for the prevention or self-management of chronic conditions.
- Describe the current telehealth landscape.
- Explain the requirements for billing for telehealth services.
- Differentiate among the codes allowed for telehealth billing.
- Identify the key components of collaborative practice agreements (CPAs).
- Co mpare and contrast different state-level pharmacist prescribing models.
- Give examples of state-level pharmacist prescribing that provide opportunities for reimbursement.
Managing the Business of Pharmacist Patient Care Clinical Services
ACPE: 0204-0000-23-828-H04-P
- Explain the steps required to implement pharmacy services in ambulatory care settings.
- Identify key stakeholders for support of ambulatory patient care services provided by pharmacists.
- Describe the components of a business plan.
- Compare key performance indicators (KPIs) used to demonstrate the effectiveness of ambulatory patient care clinical services provided by pharmacists.
- Develop a plan for a successful pharmacist ambulatory care service model in one's practice setting.
- Explain the impact of pharmacists on practice expenses.
- Describe the relationship between pharmacist services and increases in prescription capture.
- Describe the purpose of credentialing healthcare providers.
- Explain the initial steps pharmacists should take to establish contract relationships with commercial health plans.
- Explain the process of electronically determining patient eligibility for medical billing.
- D escribe strategies to ensure payment for eligible billed services.
- Summarize components of an electronic remittance advice and how it can be used to manage claim denials and payments.
- Identify key strategies in implementing medical billing in different practice settings.
- Describe opportunities for funding pharmacist patient care clinical services other than direct billing revenue.
- Compare the risks and benefits of alternative sources for funding pharmacist patient care clinical services.
Faculty
Kristina Butler, PharmD, BSPharm, BCACP, FASHP, FOSHP
Manager, Primary Care Clinical Pharmacy Services – Oregon Region
Providence St. Joseph Health
Portland, Oregon
Allison Fay, PharmD, BCACP, BC-ADM, CPP
Clinical Pharmacist
The Family Health Centers
Asheville, North Carolina
Kristi Fowler, BSPharm, RPh
Director, Medicaid Pharmacy Capability & Growth
UnitedHealthcare Community & State
Minnetonka, Minnesota
Mary Ann Kliethermes, BSPharm, Pharm.D., FAPhA, FCIOM
Director of Medication Safety and Quality
American Society of Health-System Pharmacists
Bethesda, Maryland
Ashley Marie Parrott, PharmD, MBA, BCPS, BCACP
Manager, Ambulatory Clinical Pharmacy Services
Parkview Health
Fort Wayne, Indiana
Dharti Patel, PharmD
Clinical Programs Specialist
DocStation
Austin, Texas
Keenan Rea, PharmD, BCACP
Ambulatory Care Clinical Pharmacist
Augusta Health
Fishersville, Virginia
Jennifer Reiter, Pharm.D., MBA, BCACP, BCPS, BC-ADM
Pharmacy Manager – Ambulatory Care
Indiana University Health
Bloomington, Indiana
Jessica Skelley, PharmD, BCACP
Associate Professor of Pharmacy Practice
Samford University
Birmingham, Alabama
Liz Van Dril, PharmD, BCPS, BCACP, CDCES
Clinical Assistant Professor, Pharmacy Practice
Director, PGY2 Ambulatory Care Residency Program
University of Illinois, Chicago College of Pharmacy
Chicago, Illinois
Megan Wesling, Pharm.D., BCPS, BCACP, CDCES
Assistant Professor in Pharmacotherapy
University of North Texas Health Science Center
Fort Worth, Texas
Relevant Financial Relationship Disclosure
In accordance with our accreditor’s Standards of Integrity and Independence in Accredited Continuing Education, ASHP requires that all individuals in control of content disclose all financial relationships with ineligible companies. An individual has a relevant financial relationship if they have had a financial relationship with ineligible company in any dollar amount in the past 24 months and the educational content that the individual controls is related to the business lines or products of the ineligible company.
An ineligible company is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The presence or absence of relevant financial relationships will be disclosed to the activity audience.
- No one in control of the content of this activity has a relevant financial relationship (RFR) with an ineligible company.
As defined by the Standards of Integrity and Independence definition of ineligible company. All relevant financial relationships have been mitigated prior to the CPE activity.
Methods and CE Requirements
This online activity consists of a combined total of 5 learning modules. Pharmacists are eligible to receive a total of 22.5 hours of continuing education credit by completing all modules within this professional certificate.
Participants must participate in the entire activity and complete the evaluation and all required components to claim continuing pharmacy education credit online at ASHP Learning Center . Follow the prompts to claim credit and view your statement of credit within 60 days of completing the activity.
Important Note – ACPE 60 Day Deadline:
Per ACPE requirements, CPE credit must be claimed within 60 days of being earned. To verify that you have completed the required steps and to ensure your credits have been reported to CPE Monitor, check your NABP profile account to validate that your credits were transferred successfully before the ACPE 60-day deadline. After the 60-day deadline, ASHP will no longer be able to award credit for this activity.
