In a guest opinion, Richard Hughes, a professor at George Washington University School of Law in Washington, D.C., and Kala Shankle, a healthcare attorney at law firm Epstein Becker & Green, describe barriers that exist to prescribing Paxlovid to patients.
One of these barriers is a lack of a standardized pathway to bill payers for the cost of assessing if a patient is eligible for Paxlovid. For Medicare, there is no pathway at all, Mr. Hughes and Ms. Shankle said.
Pharmacists are unable to bill Medicare Part B for the cost of assessment, because they are not recognized as providers of this service by CMS.
Mr. Hughes and Ms. Shankle wrote that CMS could add a roster billing pathway, which is permitted for pharmacists recognized as mass immunizers, or create another direct billing pathway like the one that exists for pharmacists who provide COVID-19 testing.
“By providing such a pathway, CMS would better incentivize pharmacies to offer Paxlovid to patients and encourage cross-market efforts by payers to ensure a viable reimbursement mechanism,” Mr. Hughes and Ms. Shankle said.
Read the full opinion here.
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