Medication Therapy Management Toolbox
Medication Therapy Management (MTM) Services with Medicare Part D
All Medicare Part D plans are required to provide Medication Therapy Management Services for their patients who qualify for these services under current CMS policy. Unfortunately, CMS has not given the Medicare Part D plans guidelines as far as what constitutes MTM services, so the plans are free to interpret CMS policy freely as long as they are covering MTM services for the patients who qualify. Some plans (examples: Community Care Rx and Humana) are contracting with community pharmacists to provide these services, while others only cover a phone consultation with the plan's own staff pharmacists. Most plans will cover MTM services for patients who have multiple chronic disease states, are on multiple medications monthly, and have an expected drug expenditure of at least $4000 yearly. It is up to the individual plans to determine what constitutes their list of chronic disease states, how many chronic disease states a plan participant must have, and exactly how many medications the patient must be on to qualify for MTM services. These definitions vary widely among the Medicare Part D plans. There has been a political push for Medicare to provide specific guidelines on how MTM services must be delivered. At this point CMS is watching the individual plans to see what kind of MTM services they will implement, and they may use this information in the future to develop a model for MTM services.
The first step to take before you may offer MTM services is to apply for your National Provider Identification (NPI) number. Without this number you will be unable to bill for your MTM services. You can apply for your NPI at the following website: https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.instructions .
After you get your NPI you may then begin contacting the individual Medicare Part D plans to contract with them to deliver MTM services. More information is posted below about individual plans that contract with community pharmacists to deliver these services.
NEW MTM OPPORTUNITY IN NC (CheckMeds NC): The North Carolina Department of Health and Human Services has selected Outcomes to administer a Medication Therapy Management program for the state's seniors. This program was announced in July 2007, and the program was initiated in October 2007. It is funded by the North Carolina Health and Wellness Trust Fund. To register with Outcomes as a pharmacy services provider go to www.getoutcomes.com . Pharmacists must complete an online training module before they are qualified to provide these services, so go to the website and click on Pharmacist Training Program under Quick Links on the left side of the page.
All patients who are 65 years of age or older and who have a Medicare Part D plan qualify for services through CheckMeds NC. Each patient may receive one Comprehensive Medication Review (CMR) yearly, which involves meeting with a patient face-to-face, going over all of a patient's medications, screening the patient for drug interactions/adverse effects, and educating the patient about their medications. After performing the CMR you may then provide and bill for an unlimited number of other services that year, including Prescriber Consultations, Patient Compliance Consultations, and Patient Education and Monitoring. Reimbursement rates are listed below:
CMR: $50
Prescriber Consultations: $20
Patient Compliance Consultations: $20
Patient Education and Monitoring: $10
While completing the CMR you may identify other services that the patient requires. For example, if you identify a therapeutic duplication during the CMR, you will perform a Prescriber Consultation, and if there is a medication regimen change, Patient Education & Monitoring will be required. This CMR visit could be billed along with Prescriber Consultation and patient Education & Monitoring claims, and the total reimbursement would be $80. You MUST perform the CMR to activate the patient in the Outcomes system before you may bill for other services.
TIPS: If a patient qualifies for services through CCRx or Humana and you provide these services, you may also bill Outcomes for the services provided. Patient information is not pre-loaded into the Outcomes system, unlike the Mirixa online system for CCRx. When entering the patient information into the online Outcomes system for the first time, use their Medicare Part D identification # as their Outcomes identification number.
More information: see http://www.checkmedsnc.com/index.aspx for more information, and feel free to refer your patients to this site for more information about the services offered.
Community Care Rx
All pharmacists affiliated with a community pharmacy are eligible to contract with Community Care Rx (CCRx)/Memberhealth to deliver MTM services. Ambulatory Care or Long Term Care pharmacists may only bill for MTM services through this plan if they are also affiliated with a community pharmacy. CCRx utilizes www.communitymtm.com (website name changed in 2007 from Community MTM to Mirixa) to allow pharmacists to deliver and bill for MTM services online. Pharmacists can go to the website and sign up to provide services by signing an online contract. The website also offers online training and live tutorials on delivering MTM services under the Training & Support page. Use of the website is free of charge for pharmacists. CCRx covers one medication review session for ALL patients covered under CCRx who qualify for MTM services, as well as one follow up visit per year. The MTM services are reimbursed at a rate of $60 per 30 minute session with a pharmacist. Patient qualification requirements for MTM services are listed below:
1) Patient must have an expected drug expediture of at least $4000 yearly
2) Patient must take 10 or more prescriptions from at least 4 drug classes
3) Have at least one of the following conditions: diabetes, dyslipidemia, hypertension, congestive heart failure, COPD, and asthma.
Depending on how many Community Care Rx patients you have at your pharmacy, you may not get many assigned cases until May or June. After May/June you should have a steady number of cases until the end of the year. If you have cases assigned to your pharmacy that you do not work by the end of the year, these cases will be assigned to call centers for MTM services and your pharmacy will miss the opportunity to bill for the services. To find out more information about CCRx go to: http://www.ncpanet.org/ccrx/mtm.php
American Pharmacists Association (APhA) Support
APhA has many resources available to pharmacists to assist them when they are trying to start delivering MTM services. Go to http://www.aphanet.org/AM/Template.cfm?Section=MTM_Services&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=51&ContentID=3964 and click on the links available to access their MTM tools. One of the tools they have available is an 84 page listing of all of the MTM representatives for MTM plans all over the United States. The document is arranged by state, so it is easy to find the representatives for plans offered in your state, and the phone numbers and email addresses of the plan representatives are listed. The plan listing document is available at: http://www.aphanet.org/AM/Template.cfm?Section=Home&CONTENTID=4607&TEMPLATE=/CM/ContentDisplay.cfm I have personally contacted each of the plans that provides Medicare Part D services in North Carolina, and I will post information to this page as I find out more information. If plans do contract with community pharmacists to provide MTM services I will provide detailed information below about that plan, how to contract with them, and how to bill for your services through that company. If the company does NOT contract with community pharmacists to provide MTM services (they use their in-house staff to provide MTM services) I will post their information on the list at the bottom of this screen.
There are also many software packages offered by individual companies that assist pharmacists with MTM service documentation, MTM service billing, scheduling MTM appointments, communicating with patient providers, and much more. APhA has developed a document detailing some of those software packages and web-based systems. That document is available at: http://www.aphanet.org/AM/Template.cfm?Section=Home&CONTENTID=5071&TEMPLATE=/CM/ContentDisplay.cfm .
Humana
Humana does contract with community pharmacists to provide face-to-face MTM services to patients who meet Humana's eligibility requirements. Humana's requirements are as follows:
1) Patients must be diagnosed with 2 or more chronic health conditions (hypertension, dyslipidemia, diabetes)
2) Patients must utilize 5 or more unique medications covered by Humana in a 90 day time period
3) Patients must have a total yearly drug cost of at least $4000 in 2007
Qualifying Humana members are enrolled in MTM services and are eligible for an entire year. After that year they are reevaluated to determine if they still qualify for MTM services. When members qualify for MTM services they are notified via their monthly SmartSummary Rx, which they will receive by mail. On this document they are directed to call Humana and speak with a Customer Service Representative (CSR). The Humana CSR will then contact a participating pharmacy in the patient's geographic region so that an appointment may be scheduled for the patient. The Pharmacy will receive a copy of the patient's SmartSummary Rx, as well as other patient specific information, via email or fax before the scheduled consultation (You could get patients referred from other pharmacies if that patient's regular pharmacy does not provide MTM services).
Pharmacy Requirements: Pharmacies providing MTM services for Humana must identify a pharmacist to provide the services, and the appointments must be scheduled during a shift overlap with another pharmacist or during times of low prescription volume. Pharmacies must have a private or semi-private area in which to provide the MTM services. The pharmacist providing the MTM service must be familiar with updated clinical treatment guidelines, including: JNC VII, American Diabetes Association Guidelines, National Cholesterol Education Program (NCEP) Guidelines, American Geriatric Society National Clinical Guidelines, and the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.
To find out more information on the Humana MTM program, go to the following website: http://www.humana.com/providers/tools/prescription_tools/mtm_resources.asp .
Plans that do not contract with Community Pharmacists to provide MTM services
Aetna: Medicare Part D plans only allow for MTM services delivered by phone by pharmacists employed by Aetna.
Unicare/Wellpoint: Plans do not cover face-to-face interventions by a pharmacist for 2006 and 2007, although they may implement interventions by a community pharmacist in 2008. MTM services currently delivered by phone by in-house staff.
Pennsylvania Life / Pharmacare: Currently uses in-house staff to provide MTM services.
Medco / United American: Uses in-house pharmacists to provide MTM services.
Partners: Uses in-house pharmacists to provide MTM services.
United Healthcare / Ovation / Prescription Solution: Although some plans covered face-to-face consultations with community pharmacists in 2006, the plans for 2007 will not contract with community pharmacists. In-house pharmacists & mailings will be utilized to provide MTM services in 2007.
