BCACP Ambulatory Practice Business Models 2 — Questions and Answers
Question 1: Which billing model allows pharmacists to bill for cognitive services under a 'incident-to' arrangement in an outpatient clinic?
- Pharmacy Benefit Manager (PBM) model
- Incident-to physician billing under Medicare Part B (Correct answer)
- Medicare Part D medication management
- State Medicaid fee-for-service
Correct answer: Incident-to physician billing under Medicare Part B
Incident-to billing under Medicare Part B permits pharmacists to bill for services provided as an extension of a physician's care in an outpatient setting.
Question 2: A pharmacist-run anticoagulation clinic wants to demonstrate its value to hospital administration. Which metric is MOST compelling for a business case?
- Number of INR tests performed monthly
- Reduction in warfarin-related hospitalizations and associated cost savings (Correct answer)
- Average time-in-therapeutic range (TTR) percentage
- Number of patient education sessions completed
Correct answer: Reduction in warfarin-related hospitalizations and associated cost savings
Demonstrating cost avoidance through reduced hospitalizations directly speaks to the financial return on investment for administration.
Question 3: In a Patient-Centered Medical Home (PCMH) model, the ambulatory care pharmacist's role is BEST described as:
- Independent prescriber operating a separate clinic
- Integrated team member providing medication management within care coordination (Correct answer)
- Consultant who reviews charts remotely without patient contact
- Dispenser responsible for medication synchronization only
Correct answer: Integrated team member providing medication management within care coordination
In PCMH, pharmacists are embedded team members who contribute to coordinated, comprehensive care for the patient panel.
Question 4: Which reimbursement mechanism most directly supports pharmacist-provided Medication Therapy Management (MTM) services under Medicare?
- Medicare Part A inpatient DRG payments
- Medicare Part B incident-to billing
- Medicare Part D standalone MTM program funding (Correct answer)
- Medicare Advantage supplemental benefit payments
Correct answer: Medicare Part D standalone MTM program funding
Medicare Part D requires Prescription Drug Plans to provide MTM programs for targeted beneficiaries, funding pharmacist-delivered services.
Question 5: A collaborative practice agreement (CPA) in an ambulatory care setting PRIMARILY enables pharmacists to:
- Independently diagnose new disease states without physician involvement
- Initiate, modify, or discontinue drug therapy under defined protocols (Correct answer)
- Bill independently as a Medicare provider without physician supervision
- Operate a dispensing pharmacy without a pharmacy license
Correct answer: Initiate, modify, or discontinue drug therapy under defined protocols
CPAs authorize pharmacists to manage drug therapy under pre-agreed protocols in collaboration with a supervising physician.
Question 6: When developing a business plan for a new ambulatory pharmacy service, a break-even analysis is used to determine:
- The maximum number of patients the clinic can serve
- The volume of services required for revenue to equal total costs (Correct answer)
- The quality metrics needed for NCQA accreditation
- The staffing ratio of pharmacists to technicians
Correct answer: The volume of services required for revenue to equal total costs
Break-even analysis calculates the service volume at which total revenue equals total fixed and variable costs.
Question 7: A federally qualified health center (FQHC) pharmacist provides clinical services. Under the FQHC prospective payment system (PPS), how are pharmacist services typically reimbursed?
- Separately billed as independent pharmacist services per CPT code
- Bundled into the FQHC per-visit encounter rate (Correct answer)
- Paid via a value-based care quality bonus only
- Reimbursed directly through Part D regardless of service type
Correct answer: Bundled into the FQHC per-visit encounter rate
FQHC services are reimbursed at an all-inclusive per-visit PPS rate that bundles all covered services rendered during the encounter.
BCACP Ambulatory Practice Business Models 2
Which billing model allows pharmacists to bill for cognitive services under a 'incident-to' arrangement in an outpatient clinic?