The Evolution of the First Pharmacy CSAO
The Clinical Services Administrative Organization (CSAO), represents a paradigm shift in how pharmacies operate, bill, and thrive in modern healthcare. As an organization our goal is to facilitate a simple and sustainable infrastructure for pharmacist provided clinical services reimbursement. For too long the traditional PSAO model has been the primary source of revenue supporting the pharmaceutical industry. This model centers the reimbursement paradigm around the procurement and dispensing of medications, completely ignoring the profound clinical value pharmacists provide to their patients daily. Provider CSAO stands as the premier network to bridge this critical gap, establishing direct contracts with medical payers and advocating for pharmacists in the form of service-based reimbursement. This gap between the services pharmacists can and do provide their patients and the metric by which pharmacies get reimbursed will be referred to as the “reimbursement disconnect”.
Before establishing a solution to the “reimbursement disconnect” we must first understand sources of confusion that have prevented a service-based reimbursement modality. To do this we will first establish a few definitions that the market tends to use interchangeably. These terms are Scope of practice V.S. Pharmacist provider status and Contracting V.S. Credentialing.
Scope of Practice V.S. Pharmacist Provider Status
What exactly is pharmacist provider status and how is it impacted by pharmacist scope of practice? Both terms are state specific and can vary state to state. Every state has an outlined pharmacist scope of practice. This tells pharmacists what services they are allowed to provide to their patients and what the limitations on those services are. Examples of this can range from a pharmacist’s ability to dispense medications, council patients on the safe and effective use of these medications, pharmacist prescriptive authority, and services pharmacists can provide that require a collaborative practice agreement or CPA. Pharmacist scope of practice puts to paper what a pharmacist can do. It does not outline how a pharmacist can or must be paid for these services. Pharmacist provider status on the other hand is a legal framework that establishes the pharmacist as a “provider” in an individual state. Provider status is important because it outlines in legal terms what clinical professionals can be reimbursed for services by state sponsored health plans. This does not prevent private payers from reimbursing pharmacists for clinical services. Achieving in network status for a pharmacist as a provider with a commercial medical plan is not limited by state provider status. So this begs the question then. Why aren’t pharmacists getting reimbursed for clinical services where available?
Enter Provider CSAO - The First CSAO
Contracting V.S. Credentialing
To get reimbursed as an in network provider, you must be contracted and credentialed with each individual payer you intend to bill to. Getting credentialed is typically only step one in the clinical services reimbursement process. This step can be complex and is a well established mandatory part of the contracting process. Provider CSAO handles the entirety of the credentialing process for our clients and communicates regular updates along the way. The realm where Provider CSAO truly shines is in the contracting process. We have and continue to develop relationships with every major commercial payer as well as understand to the turns and pitfalls of even the most complex state Medicaid provider enrollment process for states that have pharmacist provider status in place. It is important to note though that Provider CSAO has pharmacists billing and getting reimbursed for clinical services in states that have not established pharmacist provider status.
We created the first CSAO out of a clear market need. Current pharmacist reimbursement incentives are misaligned with the value that pharmacists provide to their communities. This has created a “reimbursement disconnect” that places value on drugs rather than people and on rebates over outcomes. Provider CSAO will change that by realigning incentives to create a more sustainable and equitable healthcare ecosystem.
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