CPESN Pharmacist Medical Billing Initiative

The CPESN Pharmacist Medical Billing Initiative helps community pharmacists build confidence and capability in medical billing for pharmacist‑provided services. The initiative supports pharmacies at every stage of the learning curve by combining practical education with access to vetted Technology Solutions Providers that meet CPESN standards.

Recognizing that pharmacist scope of practice varies by state, the initiative is designed to align billing support with each state’s regulatory landscape and opportunities for clinical services.

Purpose and Goals

The primary objective of the initiative is to help community pharmacies get paid more efficiently for non‑dispensing, professional services. This is accomplished by:

• Providing educational tools that explain medical billing and revenue cycle processes in a pharmacy‑relevant way
• Identifying and validating Technology Solutions Providers that meet CPESN’s ongoing compliance expectations
• Supporting sustainable workflows that integrate documentation and billing into day‑to‑day pharmacy operations

Supporting Pharmacies Through Complexity

Becoming enrolled or credentialed as a medical provider pharmacist can be complex and time‑consuming. Selecting the right Technology Solutions Provider is a critical decision, as it directly impacts a pharmacy’s ability to deliver and bill for clinical services with confidence.

Common challenges include:

• Aligning documentation and billing requirements with existing pharmacy workflows
• Implementing effective revenue cycle management to reduce claim rejections and payment delays
• Ensuring billing and reconciliation processes are scalable and sustainable over time

The initiative helps pharmacies navigate these challenges by promoting solutions that support accuracy, efficiency, and long‑term success.

Commitment to Pharmacy Ownership and Sustainability

A key priority of the Medical Billing Initiative is reinforcing that pharmacies own their data and their patient relationships. Access to pharmacy data is essential for informed business decision‑making and for understanding how to best serve patients.

Long‑term sustainability depends on pharmacy teams understanding medical billing and revenue cycle fundamentals. The initiative supports this by encouraging solutions that empower pharmacies to build, manage, and submit claims directly to payers—while maintaining control over their data and clinical services.

Technology Solutions Provider Vetting and Oversight

Technology Solutions Providers participating in the CPESN Pharmacist Medical Billing Initiative undergo a rigorous vetting process. Providers must demonstrate:

• An understanding of differences in state‑specific pharmacist scope of practice and billing requirements
• A fair and transparent fee structure
• Positive customer support and service practices
• Recognition that pharmacies retain ownership of their medical billing data
• Recognition that the pharmacies, or the local CPESN network own and control payer contracts

Providers that meet these criteria are offered a CPESN data‑sharing agreement. This agreement enables secure submission of non‑PHI medical billing claims data associated with processed encounters to CPESN. The aggregated data is then made available to participating CPESN pharmacies through the CPESN Business Intelligence dashboard.

Ongoing Compliance and Quality Review

Approved Medical Billing Initiative Technology Solutions Providers agree to ongoing compliance and quality oversight. Reviews are conducted by the CPESN Medical Billing Compliance Subcommittee, which reports to the CPESN General Compliance Committee.

As part of this process:

• Approved providers submit weekly data files
• The subcommittee conducts monthly reviews of submitted data
• Any negative findings are escalated to the CPESN General Compliance Committee for further action

This ongoing oversight helps ensure consistency, transparency, and continued alignment with CPESN standards.

CPESN Pharmacist Medical Billing Initiative Lead: Travis Wolff, [email protected]