Case Study
Sponsored by an educational grant from QuidelOrtho
Promoting pharmacy sustainability through reimbursement
For many pharmacies, billing and obtaining insurance reimbursement for patient testing, treatment
and counseling can be very time consuming and frankly onerous. To address the reimbursement barrier
at Harps, Jennifer has streamlined reimbursement and explained their process: “To be honest, it can be
time consuming on the front end when you’re developing your process. But once your system is in place
and your team is trained, it becomes a smooth and sustainable workflow.” At Harps pharmacies, they
discovered a way to bill medical claims through their pharmacy management system to help streamline
the claim creation and submission process. In a nutshell: When a patient enters the pharmacy for a
test-and-treat service, a technician takes their insurance card and verifies eligibility and benefits. They
make sure the patient’s insurance is active on the date of service and they verify what kind of copay
deductible or co-insurance the patient may have. Then they collect that amount, the patient receives
the service, and the patient is on their way to feeling better. The technician completes the interaction
when they bill the appropriate CPT code in the pharmacy management system.
Duane and Jennifer want to share this workflow with other pharmacies to help them build their process,
empower their staff, and make reimbursements totally manageable. But will this make community
and independent pharmacies more sustainable? “Yes!” according to Jennifer. “It really comes down
to getting more payers on board. The more payers that we have that recognize and reimburse us for
the value of these services offered in the pharmacy setting, the more successful and sustainable we
will be.” This workflow is described as win-win. The patients receive fast, convenient access to care,
and pharmacy viability and sustainability are supported. Duane recommends the National Community
Pharmacists Association (NCPA)6 and the Community Pharmacy Enhanced Services Network (CPESN)7
for resources on implementing test-and-treat programs and to find out about individual state laws
governing pharmacists and reimbursement. Pharmacies will have to contact their Department
of Health to inquire about reporting requirements and CLIA waiver, and then will have to ensure both
the pharmacist and pharmacy are credentialed by the various payers.
data entry, product dispensing, and managing the adjudication queue. Another key part of the
workflow is medication synchronization that allowed Harps to transition a majority of their
prescription workload from acute to scheduled, so pharmacists have more flexibility to step
away from the verification queue when they need to see a patient.
...it can be time
consuming on the
front end when
you’re developing
your process.
But once your system
is in place and your
team is trained,
it becomes a smooth
and sustainable
workflow.”
Jennifer Griffin, PharmD, MS
Test-and-treat
-
• Data entry
• Product dispensing
• Manage adjudication queue
• Input medication synchronization
for new prescriptions
• Medication verification queue
• Patient counseling and education
• Point-of-care testing
and resulting prescriptions
Roles
Pharmacy Technician:
Non-clinical responsibilities
• Determines what point-of-care test is needed
• Performs test and obtains results
• Writes prescription or refers patient
to local physician if symptoms are severe
• Returns information to pharmacy technician
for appropriate CPT code billing
• Verifies insurance eligibility and benefits
• Ensures insurance is active
• Handles payment
• Bills appropriate CPT code
in pharmacy management system
Pharmacist:
Clinical responsibilities
Workflow
6. NCPA - National Community Pharmacists
Association. Accessed May 27, 2025.
https://ncpa.org
7. Community Pharmacy Enhanced Services
Network CPESN. Cpesn.com.
Accessed May 27, 2025. https://cpesn.com
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