Building Community, Building Credibility

Accreditation is not just about revenue streams — it's also about being able to service your community.

Pharmacy AccreditationLike other DME retailers, pharmacies that want to sell Medicare-reimbursable products first need to become accredited. The reason, according to Rhonda Pearce, director of operations for Healthcare Quality Association on Accreditation (HQAA), is that accreditation ensures that an organization is operating at a higher level of quality due to having more uniform practices and processes in place. Pharmacy accreditation helps:

  • Create policies and procedures that follow CMS quality standards, federal and state guidelines, and good business practices
  • Implement policies and procedures throughout the organization
  • Ensure all staff are involved in the accreditation process

“Once all policies and procedures are implemented, a site visit will be performed to ensure the organization is following their policies and procedures, as well as regulations,” she notes. “A surveyor visit validates that what an organization indicates on paper is what their practices are and are truly implemented as observable processes.”

The overall accreditation process for pharmacies is similar to non-pharmacy DME retailers, and their motivations for going through the process include creating new revenue streams, as well as serving the needs of their community.

“We have some pharmacies that just get into it to sell canes, crutches, and walkers and then eventually get into renting, like in the resort areas where they might want to rent wheelchairs for people who are just visiting,” says Tim Safley, MBA, RRT, RCP, director of DMEPOS, Pharmacy and Sleep at the Accreditation Commission for Health Care (ACHC). “I’ve seen more and more pharmacies getting into it for the revenue stream even though there is not a lot of money there. But carrying Medicare-reimbursable products helps with the walk-in business.”

Sandra Canally, president and founder of The Compliance Team, says that all new pharmacies should pursue Medicare Part B DME. Her reason is that even if you want to keep it limited to diabetic supplies, you want the diabetics in your community to be able to come to you.

“It’s not just about what reimbursement you get for the strips,” she explains. “It’s about what that patient with diabetes is going to need from you. They’re going to need the rest of their prescriptions filled. They’re going to need incontinence supplies. They’re going to need foot care. They’re going to need sugar free candy, and on and on. That’s one of the main reasons new pharmacies should not, right out of the gate, say, ‘Oh, we’re not going to make enough money off of diabetic strips to even go down that road and then have to get accredited.’ It’s about serving your community, serving the diabetic population.”

Considering Pharmacy Accreditation

A lack of industry data on reimbursable sales makes it difficult to pinpoint how many pharmacies become accredited in pursuit of generating more revenue streams. But knowing how accreditation helps build your business is a motivating factor for going through the process.

Canally says that accreditation is the gateway to entry in getting a Medicare Part B number for DME. The process, she explains, is directly tied to billing privileges and the products that pharmacies provide. Important to remember is that the accrediting organization (AO) reports the products that the pharmacy gets accredited back to CMS. Therefore, knowing your business and customers needs are paramount to successful accreditation.

“Let’s say a new pharmacy just opened up and it wants to provide everything to their community,” she says. “If they decide, ‘Okay, Mrs. Jones needs a nebulizer or she needs a CPAP, I’m trained on that; I know how to do that,’ but the accreditor hasn’t accredited them for that product line and so hasn’t reported it to CMS, then the pharmacy is going to submit the claim and CMS, in turn, is going to say, ‘Oops, this product isn’t on their list as an accredited item.’ They would then reach out to the pharmacy’s accreditation organization and ask us, ‘Did you accredit them for this product?’ If the answer is no, then we as the accreditor are then going to contact the pharmacy and say, ‘Okay, this is what you need to do in order to add that to your list of accredited items.’ It may be proof of training. It may be policies and procedures for providing a nebulizer, CPAP, or whatever. Or it may, depending on what it is, require an additional visit.”

New pharmacies should know that it is not the responsibility of the manufacturer not to sell you Medicare-reimbursable products that you are not accredited to sell.

Aside from Medicare revenue, Safley notes that some states require that if you want to do anything in Medicaid or DME, you also have to be accredited for Medicare. In addition, he says if pharmacies want to bill some private insurances, they could require accreditation. So even if you don’t want to compete in the Medicare market, there are still other reasons to get accredited.

Pearce pointed out that pharmacies, especially in isolated, rural areas, should consider carrying DME products to better serve patients and help them meet their needs.

“I think the most important reason to get accredited is that old saying, ‘You don’t know what you don’t know,’” Safley says. “Remember, if a pharmacy gets an exemption, they still have to comply with all the Medicare Part B rules. I cannot begin to tell you how many times I’ve gone into a pharmacy or Medicare has walked into a pharmacy and they didn’t meet all of the Medicare supplier standards Part B rules, or equality standards. Just because they’re exempt from accreditation doesn’t mean they’re exempt from following the Medicare Part B participant rules.”

Pharmacies that meet certain criteria may file an accreditation exemption statement, which enables them to sell Medicare-reimbursable products without having an accreditation. The criteria include:

  • The pharmacy has been enrolled as a DMEPOS supplier for at least five years.
  • The pharmacy has not had an unrescinded final adverse action over the past five years.
  • The pharmacy has no more than 5 percent of sales from DME products.

For a complete list of criteria, visit cms.gov and search “pharmacy accreditation exemption”.

Steps Toward Accreditation

Before you start the process, first and foremost, Safley says, make sure you understand why you’re getting accredited. A lot of company’s are just assuming they need to get accredited without doing any research. Know what your accreditation goals are.

From there, it’s about who’s on your team.

“Make sure you have the staff to comply with all the rules, regulations and data that is needed for accreditation,” he says. “You can’t just say, ‘I’m going to get accredited,’ and expect somebody to do it. You have to have the staff to help you get ready.”

Canally suggests identifying someone from the pharmacy to spearhead the process.

“It can’t be the pharmacist in charge, because he or she is too busy filling prescriptions and it’s really difficult for that person to take this on,” she says. “In terms of preparation, putting personnel files together and putting patient files together with the appropriate documentation could be done by one of the techs. ... You should be able to have one person working with your AO, which typically takes dedicating about four hours a week on their part to implement. That’s not a lot. Again, we give them the tools so they can identify, ‘OK, we’ve got this, and we’ve got that.’”

Safley suggested going to cms.gov and downloading form CMS-855S, which is the Medicare enrollment application for DMEPOS suppliers. The form highlights standards you must meet to submit claims for payment.

Canally adds to do your research by looking at the Local Coverage Determination (LCD) criteria (located on the cms.gov website), which spells out what the pharmacy needs to have in order to meet the requirement to bill.

“Next is having contracts with the various manufacturers and making sure that they have the training to provide these products,” she says. “Most manufacturers will provide a rep to come onsite to the pharmacy or the DME and provide some training for the staff.”

If you’re a new pharmacy, you won’t qualify for the exemption, but if you have been a supplier for at least five years, you should look into whether you qualify for an exemption to accreditation.

Before hiring a consultant to help with the accreditation process, you might want to check with the AO you are going to use to see what they offer regarding preparatory information. For example, Canally says that The Compliance Team on the front end provides services through a series of webinars for walking new customers through the process, as well as the accreditation standards. They offer self-assessment checklists and various tools to use to prepare.

“Then when we feel that they are ready for a visit, some-one from The Compliance Team goes on site,” she says.

Safley notes ACHC just opened Accreditation University, where pharmacies can get on the phone and get an hour-long conference to learn more about the process. ACHC’s website has a list of certified consultants if you prefer going that route for help. He also says other ways of finding information to help you through the accreditation process includes attending Medtrade, VGM or The Med Group workshops.

“Accreditation will provide you opportunity, whether it’s to get into Medicare or whether it’s to get in to other networks,” Safley says. “It will give you opportunity and provide you walk-in business that you might not get otherwise. Or maybe you’re doing it just to help support the community. If that’s your main goal then I think you’re on the right track too.”

Canally says that the typical pharmacy needs between four and six months to prepare for accreditation and that hands down, the biggest hurdle is a lack of written documentation. Challenges include pharmacies not having all their policies written down, missing proof of delivery, and a lack of instruction for the patients, or patients not signing off on them.

“It’s those types of things that you run into with pharmacies more than traditional DMEs,” she says. “It’s certainly a lot of paperwork that is tied to doing Medicare and meeting the standards.”

Choosing an AO

One of the biggest decisions you will make in the accreditation process is choosing your accreditation organization, or AO. There are nine of them, some with a greater number of approved categories and different standards. Canally suggested the following when choosing an AO:

  • “Get a copy of the AO’s standards. It’s all about the quality standards and the pharmacy having to meet them. If they get a copy of the standards and they can’t understand them, move on. If you can’t interpret the standards that are designed for your operation, then how can you get your staff trained? You will end up hiring an outside person to come in to interpret. That doesn’t make any sense.”

“Choose an AO that is adaptable, easy to reach, and user friendly. Some accreditors write their standards in obtuse language, making it all about the accreditor. The accreditor says, ‘You must have it this way.’ The reality is, ‘Okay, we have this set of standards, but we’re not going to hold you to standards that don’t apply to your operation. We’re not forcing you to transform your business model in order to get accredited by us.’ It’s got to be about you, the company needing accreditation, and not the AO.”

This article originally appeared in the DME Pharmacy June 2016 issue of HME Business.