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Provider Status: Because Your Patients Need You

Achieving provider status is about giving patients access to the valuable care that you provide. Becoming a “provider” in the Social Security Act means that patients can pharmacists can participate in Part B of the Medicare program and bill Medicare for services that are within their state scope of practice to perform.

 

H.R. 4190

H.R. 4190 will enable Medicare beneficiaries’ access to pharmacist-provided ambulatory-based patient care services under Medicare Part B by amending section 1861(s)(2) of the Social Security Act. These services would be reimbursable under Medicare Part B if they are provided in medically underserved communities and consistent with state scope of practice laws.

Scope

  • Who– State-licensed pharmacists who may have additional training or certificates depending on state laws.
  • What – Pharmacist services according to state scope of practice.
  • Where– Medically underserved communities (i.e., Medically Underserved Areas (MUAs), Medically Underserved Populations (MUPs), or Health Professional Shortage Areas (HPSAs) as designated by the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA)).
  • Reimbursement– Consistent with Medicare reimbursement for other non-physician practitioners, pharmacist services would typically be reimbursed at 85% of the physician fee schedule.

Key aspects of legislation

The bill seeks to increase access and improve quality by enabling pharmacists to provide patient care services as consistent with their education, training and license. Importantly, the federal legislation would not expand the types of services that pharmacists are permitted to provide. Eligible services would continue to be governed by state laws just as they are for other health professions.

The legislation promotes increased access to care for patients who are otherwise medically underserved. Specifically, the legislation focuses on care for underserved beneficiaries in MUAs, MUPs, and HPSAs, as designated by HRSA. As the shortage of primary care physicians increases, so too will the challenges that patients in underserved communities face, especially those related to access. This legislation can help address provider shortages and access issues in underserved areas.

The bill promotes cost-effective health care by increasing access to care and opportunities for early intervention at cost-effective settings so as to minimize long-term health care costs such as those associated with preventable higher-cost conditions. Consistent with precedent established in the Social Security Act for nurse practitioners and physician assistants, pharmacist services would be reimbursed at 85% of the physician fee schedule, unless they are operating under the direct supervision of a physician, in which case they would be reimbursed at 100% of the physician fee schedule.

ASHP, as part of the Patient Access to Pharmacists’ Care CoalitionExternal Link, was instrumental in shaping H.R. 4190.

 

Take Action!

Ask Your Member of Congress to Support H.R. 4190

As a pharmacist and a constituent, you have tremendous influence with your members of Congress. And as ASHP and the profession work to build support for H.R. 4190, it is more important than ever for you to reach out to your elected officials so that they understand how provider recognition will improve patient care for some of our nation’s most vulnerable patients.
Here’s what you can do:

  • Contact your representative and ask them to co-sponsor H.R. 4190. Personalize the provided email with examples from your practice that demonstrate your critical role on the health care team.
  • Make an appointment to meet with your House member while he or she is back home during a recess or district work period. Use this opportunity to go into more detail about your work with patients.
  • Ask colleagues at your practice site to join you. Every voice counts!


It's a critical time! Because it is late in the Congressional session and an election year, it is important that we lay the groundwork so that legislation will be quickly reintroduced in 2015.

 

Member Spotlights

Achieving Provider Status One Letter at a Time
Achieving Provider Status One Letter at a Time: Mollie Ashe Scott, Pharm.D., BCACP, CPP, embarked on a highly effective-letter writing campaign to support provider status. Learn More

Making the Case for H.R. 4190 with the Cleveland Clinic C-Suite
Large healthcare systems can often wield substantial political clout on important patient care issues like provider status. Scott Knoer made the case for H.R. 4190 with the C-Suite at Cleveland Clinic. Read MoreExternal Link

Students Take to Capitol Hill for Provider Status
Fifteen pharmacy students answered ASHP's call to spend September 17 on Capitol Hill as part of a group advocating to grant pharmacists status as healthcare providers in the Medicare program. Read moreExternal Link