Billing for MTM Services – What a …. Headache!

As mentioned in my first blog, I am currently working on implementing MTM services at Ridgeview Medical Center (Waconia hospital) and their associated outpatient clinics.  I think each person I talk to and each answer I get, I am left with 20 more questions!

A concern right now is that Ridgeview is not contracted with Medicare Part D, so I need to find out how to do this and make sure it is “worth it” to them!  Completely at a loss of ideas, I contacted various faculty and residents at the U of MN College of Pharmacy and other pharmacists that have started up MTM services at other locations.

The location of Ridgeview has only about a 5% Medicaid population, meaning billing the state for MTM services will not be a meaningful way to sustain this service.  We need other payers!  It is my understanding that Ridgeview may be able to contract with individual private payers to cover this service, but I still need to find out.  It seems that we need to work directly with the Part D providers to contract for this service.  In this area, the only Part D plans contracting for MTM services are Humana, Medica, and Health Partners.  Humana and Medica are already contracted through Outcomes, but I am not sure if they also will contract with others for MTM services or if pharmacists must use Outcomes to bill.  If pharmacists must use Outcomes, this might not fit with the Ridgeview MTM model since they don’t have outpatient retail pharmacies. 

Next week I have a meeting with Medication Management Systems (MMS), a company that specializes in helping health plans and PBMs to implement MTM programs.  This could be just what we need, and I will keep my blog updated with any findings so future pharmacists implementing MTM programs can have some guidance!

Another topic I have researched this week is the benefits of a having a pharmacist in pay-for-performance healthcare settings. It seems to be an opportunity and a way to help justify clinical pharmacy services.  However, since pay-for-performance is really just emerging it is likely that no one has had enough experience with it yet to evaluate this very well. It has been difficult to find anything significant published on this yet. If anyone has any helpful resources, please comment!

I visited the Minnesota State Capitol on Wednesday for a tour.  I got to hear about the capitol’s history, art, and architecture and see the different chambers where our government makes decisions.  It was the first time I had been there since middle school, and it was truly stunning to see the beautiful architecture. I ended the week working on excerpts for MPhA’s November CAPS newsletter.  Please be sure to read the newest CAPS on the website!