COVID-19 Test-to-Treat for pharmacy is finally here. How can pharmacy execute a successful test and treat program? That was the topic of a webinar last Tuesday by Drug Store News, presented by OmniSYS, which featured David Pope, chief pharmacy officer of OmniSYS; Harley Ross, chief commercial officer of XIFIN; and Shelley Hansell, OmniSYS executive vice president of client relations and RCM product management.
Pope said that in order to prescribe Paxlovid, pharmacies will need to have labs and perform medication and OTC reviews and medical history.
“This represents a problem. It’s a lot of work. How do we work through those things and leverage patient engagement technologies? There’s going to be some pharmacy workflows that are unique to you. This is our time to seize the moment,” Pope said. “From pharmacists to pharmacy to pharmacy organizations, we have to do this together. Let’s make sure we show the country, just as we did with immunizations, that we are ready, willing and able, and excited about prescribing inside the pharmacy.”
[Read more: XIFIN acquires OmniSYS]
On the subject of claims processing for COVID-19 tests, Pope provided the scenario in a physician practice when patients come in and say that they are sick and not sure if they need a strep or flu test. “Ultimately, there’s an evaluation,” he said. “Think of evaluation as an office visit. The evaluation is an office visit code if you were to go to a non-pharmacy healthcare institution.”
The next step that is crucial for pharmacists is to ask the patient questions. “We say, we’re going to test you and that is based on medical necessity. I have medical necessity, I can now test,” he said.
Noting that following the evaluation, if the patient tests positive, pharmacists can say, “I now want to prescribe,” Pope said, “There’s an evaluation, a test and a prescription. This is how pharmacy does this. Ultimately, a patient doesn’t necessarily say, ‘I’m sick.’ Many times they come in and ask you directly, ‘I need a COVID-19 test.’ How does the healthcare system handle that? We look at step one, it starts with a COVID-19 test that still requires medical necessity. When you submit that claim, you’ll submit that test, and again that is usually billed to the medical benefit. It is normally billed under your pharmacy organization. That is very specific.”
Pope also outlined four pathways to offer as a pharmacy:
- Gather the information. That information should come from your scheduling. That data, that medical history should be populated. Those questions that your patient is answering, such as, “Are you traveling from so and so, have you been exposed to?” Those things might influence the claim itself;
- The next step is to evaluate that information for whether or not you can proceed moving forward;
- After evaluating the patient, you need to inform the patient. How can you inform them in a way that doesn’t take more people power for your people to pick up the phone? There needs to be a technology that takes all of this into account and that gathers information from your scheduling, perhaps from an electronic health record, that brings that together, that communicates with the patient and brings them back in for a final evaluation before you prescribe. You need to bring your patient in; and
- The final piece is that prescription process.
Lastly, Pope said that creating the experience for your patients is vital to make sure that before a patient walks in, they have an idea that they may be clinically and financially eligible.
OmniSYS’ Hansell discussed the complexity of the COVID-19 medical claim, noting that as we look at test-to-treat opportunities, many people do not realize that pharmacies can support this within their existing workflow.
“They often don’t realize pharmacies have been billing medical claims for over two decades,” she said. “If we look at the complexities around lab testing, as they are just starting to enter this phase, it follows a similar path. For pharmacies that have a CLIA waiver ID, that test is billed under your pharmacy organization NPI just like any other medical claim for supporting COVID immunizations or DME claims.”
Hansell also pointed out that having payer knowledge and understanding their requirements are critical in order to get reimbursement.
How are payers responding? She said that they outlined three ways pharmacists may receive reimbursement: “The pharmacist is performing three services. For a COVID-19 test, you have test and specimen collection. The workflow and pathway is consistent across all payers through the process. We know today, we have pharmacies who are successfully being reimbursed for testing specimen collection. For COVID evaluation and management, this is often referred to as an office visit. It covers the cost of evaluating the patient for a problem, not a result. Thirdly, you’ll get reimbursed for the Paxlovid prescription,” she said.
Lastly XIFIN’s Ross discussed that pharmacies are a new channel for labs to expand market share. “How do we make information and clinical data more extensible to providers, the pharmacists? To help with adherence and treatment, to make sure we are driving outcomes in a timely manner? There’s education that needs to be done in the marketplace, in lab and pharmacy. How do we collaborate with these two market segments?”
On the topic of companion diagnostics and pharmacy, Ross cited a case where a lab bought a specialty pharmacy. “They pulled this together. You can see the numbers once they learned how to get the toxicology panel integrated into the pharmacy workflow,” he said.
Going forward Ross said that from pandemic to endemic, “We’re keeping our eye on the future of test to treat, and we’re excited for this opportunity.”
Watch the on-demand broadcast here.