Examination of differences between actual and potential revenue generation in a pharmacist-run ambulatory clinic

Background

Pharmacists are not billable health care providers under Medicare Part B or most insurance plans. Because of this, pharmacist services are relegated to incident-to-provider billing, despite pharmacists routinely providing services high in complexity. This discrepancy may negatively skew perceptions of pharmacists’ contributions to outpatient clinic care.

Objective

The objective of this study was to identify the potential revenue generation for pharmacist-delivered services at a single, rural South Dakota clinic if pharmacists were considered billable health care providers.

Methods

This retrospective, single center study utilized a chart review of first-quarter data from a single ambulatory clinic served by a 0.5 full time equivalent pharmacist serving Chronic Disease Management (CDM) and COVID-19 patients. For each appointment, the chart note was reviewed for elements that would satisfy requirements for Current Procedural Terminology billing codes. Medicare and Medicaid reimbursement was determined using official 2022 Physician Fee Schedules and private insurance reimbursement was set at a single rate of 60% of the fee schedule of the most common private payer.

Results

During the 3-month study period, 118 patients (206 appointments) were seen by the pharmacist. The amount paid to the clinic was estimated at $2174.91. The hypothetical amount paid to the clinic if pharmacists were considered billable health care providers is $10,415.31 for CDM clinic and $7953.48 for COVID-19 clinic, totaling $18,368.79. Excluding uninsured patients, the hypothetical total is $17,102.03, with total unrealized revenue of $16,193.88.

Conclusion

If pharmacists were considered billable health care providers and their services were billed accordingly, the potential revenue generation is significantly higher than actually generated revenue. This estimated data can be used to better quantify and qualify appointment-related data for nonpharmacist clinic managers.