January 23, 2025 • 12 mins
In this episode, Katie Meyer and independent community pharmacist Rachel Kestin discuss her experiences and workflow tips navigating the 2025 Medicare updates.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:02):
Welcome to First Fill and Happy New Year!
As we move into 2025, this monthwe wanted to be sure to highlight
some new updates to Medicare that are happeningright now due to the Inflation Reduction Act.
If you're serving patients out in the community,you're likely
getting questionsabout the Medicare prescription payment plan.
And we're here to help provide you with answers.
(00:23):
I'll mention that if you visit our billingand payment center on pharmacist.com,
we've created a one page resourcewith support from Johnson and Johnson
for you to use to help educate your patients.
Definitely head over there and check it outand I hope that you find it extremely helpful
from a guest perspective today.
I'm pleased to introduce you to an independentcommunity pharmacist, Rachel Kestin.
(00:45):
Welcome, Rachel.
Why don't you introduce yourself
and tell our listeners a little bit about yourselfand your practice setting.
Hey, Katie.
Thanks for having me on today.
So I'm Rachel Kestin.
I am an independent pharmacistin the Greater Charlotte area with Moose Pharmacy.
My role in the company is that
I am a clinical pharmacist,I spend half my time working with Medicare
(01:09):
patients on the primary care side,working with a local primary care office
to do chronic care managementand remote patient monitoring.
And the other half of my position is a traditionaldispensing role at the pharmacies.
And in that role,like I said, traditional dispensing
as well as implementingand facilitating some of our clinical services
(01:30):
as well as precepting our communitypharmacy residents.
Thanks so much, Rachel.
I'm excited to have you here today.
So last week,Nick, Maya and I discussed the recent changes
to Medicare for 2025,including the new out-of-pocket
maximum and the Medicare prescription payment planthat's now available.
(01:50):
I'm curious to hear your perspectiveas you've been practicing over the last few weeks.
What are some of the most common questionsthat you're receiving
from patients about these 2025 Medicare updates?
Yeah, I think the one shining question
that we're getting all day, every day iswhy are my co-pays so high?
(02:14):
I think it depends on
who the patient signed up with for insurance
and like that insurance agentand what they prepare them for.
But this definitely is one of the most eye openingand like biggest co-pays that we've seen.
And so I think a lot of patients
are just very caught off guardbecause they were not expected this.
(02:34):
And they also were not aware that there'sgoing to be no coverage gap this year either.
So there's like that small silverlining that they're excited about.
But at the same time, a lot of them are justquestioning why they have such high co-pays.
And for those independent pharmacies wherewe've had, you know, an insurance agent or someone
(02:55):
who can help them choose their insuranceplan for this upcoming year.
Sometimessome of them can just get a little bit frustrated
and ask why we put them put them on this planwhere their co-pays are now so much higher.
That's interesting, Rachel.
Are you finding with the higher co-pays,that that is potentially
(03:16):
an opportunity for themto enroll in the prescription payment plan?
Or how do you kind of see thatfitting into the picture? Yes.
So I would say whenever there co-pays come back,
we have a bunch of different options for them.
First and foremost, we're very transparentabout what the situation is
and all the different updatesthat have happened with Medicare.
(03:38):
One of the options that we dogive them is telling them about this new Medicare
prescription payment plan or M3P.
Some of them are very receptive to itand some of them are not.
I think it just kind of depends on whatthe patient thinks.
Other options that we've given themare enrolling in a patient assistance program
(03:59):
or trying to find some type of grantthat helps with a co-pay, or they'll have to
just talk to their doctor and switcha different medication for them, unfortunately.
Yeah, that makes sense.
Let’s dive in or shift gears
a little bit into the M3P optionthat you mentioned.
I'm curious to your experience,the patients that have kind of elected
(04:22):
to enroll in that program,how exactly does billing work and are there
any best practices that you've learnedso far with regards to billing as part of that?
And yes, so throughout all of the pharmacies,at most pharmacy,
there's only two as of right now that I'm aware ofthat has patients that are enrolled.
And we've billed for the M3Pso far from what we've seen.
(04:46):
You bill their traditional insurance primary
and then there's going to be an additionalalmost secondary insurance,
but it's a different ID, different group
number, PCN and BIN number for the M3P.
Whenever you initially bill
their primary insurance, if they are enrolled,the way you find out they're enrolled
(05:09):
is you have to go specifically into the claimand see everything that the insurance
has given back to you,which for us in our pharmacy
software is not a normal workflow.
So depending on what kind of pharmacy
softwares are out there, all of you pharmacistslistening are going to have to really work
with them to find the best wayto find out all this information.
(05:33):
But whenever you go into that primary billing
claim, that'swhere you'll see if they're enrolled or not.
And that's where it will give you the ID number,
BIN number, PCN and group numberthat you'll use to build secondary.
That's really interesting.
Rachel.
So essentially you go into thelet me just make sure I'm understanding correctly.
(05:54):
So you go into the primary claim,it gives you the billing information for the M3P,
and then you're billing that informationas a secondary claim for the program.
And so their co-pay after a primary
might be $600 or something along that line.
And then you can go into the claimand see if they are enrolled.
(06:16):
The patient should know if they enrolled or notbecause they should have called and gone
through that process.
And but you'll be able to go into itand then you'll see all of that information.
Put that in secondaryand then their co-pay goes down to zero.
That's very interesting.
So I guess once you figure it out,
that initial part,it seems like it would be fairly straightforward.
(06:37):
It's also very helpful when the patient knowsthat they've enrolled, of course,
but I remember from my experiencepracticing in community pharmacy myself,
not only is the first of the year hecticwith the new plans, deductibles
and everything else, I think this could actuallyadd an additional layer of complexity there.
Just curious from your perspective,how you've kind of navigated
(06:58):
through any hiccups or confusionregarding the M3P?
If there's any kind of pearlsyou can share in terms of the waiting period
that Medicare has put out,
I believe they said roughly 24 hours,but that could be kind of a guideline or any other
just general best practices that you foundto ensure the best customer experience possible.
(07:19):
Yeah.
So in regards to the 24 hour waiting period,I actually had one of my technicians
tell me that she had a co-pay come upthat was really expensive.
She told the patient about it.
He called his insurance and enrolledand that same day
she was able to bill the M3P plan.
(07:40):
So I don't knowif that was just that specific plan
or if there truly is going to be a 24 hourwaiting period for other plans.
But I think you can always try itand see if it works.
And if not, you can just try it the next day.
So the waiting hour, that's just something
that we haven't seen as a hiccup yet
(08:02):
as far as like other confusionsand best practices.
Our company has seven pharmacies and so we do have
strategy callsand talk about what to do every few weeks.
And so I'd really recommend thateven if you're a one store location,
you can still strategize with your currenttechnicians, employees and cashiers.
(08:22):
And so that way everyone's on the same pageand we're telling all of our patients
the same information.
Another thing that some of our locations have doneis within our software,
we can have like a shared taskthat pops up on everyone's login.
And so whenever they figure outthat there's a patient enrolled
(08:43):
in that we've billed for the end M3Pwe'll put it in that shared task.
So that wayany computer on or whenever you're logged in,
they'll be like a little sticky notebasically that says what patients
we have at the pharmacy that are enrolled in that,which is pretty nice.
Another thing that some of our locations
have that we're trying to figure outwith our software, how to make
(09:08):
all of our
locations have is like a triggerthat pops up that any time you just send a claim
through their primary insurance,this little trigger will pop up that says,
hey, they're enrolled in M3P, Soif they're co-pays high make sure you bill that.
So that's been somethingthat we've been trying to do.
So anything that you can put in your softwarethat's basically flagging you, that says that
(09:33):
the patient is enrolled, I think is going to bea huge workflow win when it comes to this program.
Thanks, Rachel, for all of these tipsand kind of best practices
that you've learned here in the first month or soand navigating through these Medicare updates.
This has been really insightfuland I appreciate all that you're doing
on a daily basis to serve your patientsand help them navigate
(09:54):
through these higher than anticipated coststhat they're seeing.
Yeah, of course.
All right.
Well, that's all the time we have here for today.
So I'm going to go aheadand summarize our major takeaways.
First, there's a number of different optionsavailable to patients
who are experiencing higher costsat the beginning of the year here.
So these include the M3P which helpsspread their costs throughout the entire year.
(10:18):
Extra help or patientassistance plans or recommending
a lower cost medicationif one happens to be available.
To bill for a patient through the M3P
it's important to review the primary claimand within the primary claim
that will give you the BIN, PCN an ID for the M3P.
After you've located that,The M3P is then billed as a secondary,
(10:43):
and when you billthat it'll come up with the zero co-pay
in terms of kind of best practicesrelated to that.
And it's certainly important to collaboratewith pharmacists and other team members, both
within your pharmacy and throughout your network,to share those best practices.
As you all know your software better than we do,
(11:03):
but some things that Rachel mentioned
that could potentially be helpfulinclude software enhancements that
perhaps have maybe an automated triggerthat tells staff
this person,a person is enrolled in the M3P bill that plan,
and then they'll come back with a $0 co-pay.
And then you can also in termsof the kind of waiting period,
(11:26):
Rachel has mentioned, that she has some patientsthat the plan becomes active before that period.
So in some cases, depending on the plan,you may be able to build a plan
earlier than 24 hours later and don'tnecessarily have to send your patient away.
All right, folks.
Well, that's all the time we have here for today.
If you haven't listened to part one
(11:46):
of this month's first full podcast yet,it was released just one week ago.
In that episode, I hosted APhA executivefellow Nick and our newest team
member, Maya, and we reviewed detailsrelated to the Medicare updates for 2025.
And these included the new out-of-pocket maxand then details
related to the M3P that we just discussed.
(12:06):
And then as I also mentioned last week,we do have that patient
facing resource availablein the billing center on pharmacies dot com.
So go ahead and head over there.
And it's a nice printable resource
that you can hand to your patientsand use one answering question and last
but certainly not least, pleasedon't forget to head over to the learning library
at learn.pharmacist.comto earn your CE for this month’s podcast.
(12:29):
CE is available for both pharmacistsand pharmacy technicians this month,
so we hope you take advantage of it. Take care.
Welcome to First Fill and Happy New Year!
As we move into 2025, this monthwe wanted to be sure to highlight
some new updates to Medicare that are happeningright now due to the Inflation Reduction Act.
If you're serving patients out in the community,you're likely
getting questionsabout the Medicare prescription payment plan.
And we're here to help provide you with answers.
(00:23):
I'll mention that if you visit our billingand payment center on pharmacist.com,
we've created a one page resourcewith support from Johnson and Johnson
for you to use to help educate your patients.
Definitely head over there and check it outand I hope that you find it extremely helpful
from a guest perspective today.
I'm pleased to introduce you to an independentcommunity pharmacist, Rachel Kestin.
(00:45):
Welcome, Rachel.
Why don't you introduce yourself
and tell our listeners a little bit about yourselfand your practice setting.
Hey, Katie.
Thanks for having me on today.
So I'm Rachel Kestin.
I am an independent pharmacistin the Greater Charlotte area with Moose Pharmacy.
My role in the company is that
I am a clinical pharmacist,I spend half my time working with Medicare
(01:09):
patients on the primary care side,working with a local primary care office
to do chronic care managementand remote patient monitoring.
And the other half of my position is a traditionaldispensing role at the pharmacies.
And in that role,like I said, traditional dispensing
as well as implementingand facilitating some of our clinical services
(01:30):
as well as precepting our communitypharmacy residents.
Thanks so much, Rachel.
I'm excited to have you here today.
So last week,Nick, Maya and I discussed the recent changes
to Medicare for 2025,including the new out-of-pocket
maximum and the Medicare prescription payment planthat's now available.
(01:50):
I'm curious to hear your perspectiveas you've been practicing over the last few weeks.
What are some of the most common questionsthat you're receiving
from patients about these 2025 Medicare updates?
Yeah, I think the one shining question
that we're getting all day, every day iswhy are my co-pays so high?
(02:14):
I think it depends on
who the patient signed up with for insurance
and like that insurance agentand what they prepare them for.
But this definitely is one of the most eye openingand like biggest co-pays that we've seen.
And so I think a lot of patients
are just very caught off guardbecause they were not expected this.
(02:34):
And they also were not aware that there'sgoing to be no coverage gap this year either.
So there's like that small silverlining that they're excited about.
But at the same time, a lot of them are justquestioning why they have such high co-pays.
And for those independent pharmacies wherewe've had, you know, an insurance agent or someone
(02:55):
who can help them choose their insuranceplan for this upcoming year.
Sometimessome of them can just get a little bit frustrated
and ask why we put them put them on this planwhere their co-pays are now so much higher.
That's interesting, Rachel.
Are you finding with the higher co-pays,that that is potentially
(03:16):
an opportunity for themto enroll in the prescription payment plan?
Or how do you kind of see thatfitting into the picture? Yes.
So I would say whenever there co-pays come back,
we have a bunch of different options for them.
First and foremost, we're very transparentabout what the situation is
and all the different updatesthat have happened with Medicare.
(03:38):
One of the options that we dogive them is telling them about this new Medicare
prescription payment plan or M3P.
Some of them are very receptive to itand some of them are not.
I think it just kind of depends on whatthe patient thinks.
Other options that we've given themare enrolling in a patient assistance program
(03:59):
or trying to find some type of grantthat helps with a co-pay, or they'll have to
just talk to their doctor and switcha different medication for them, unfortunately.
Yeah, that makes sense.
Let’s dive in or shift gears
a little bit into the M3P optionthat you mentioned.
I'm curious to your experience,the patients that have kind of elected
(04:22):
to enroll in that program,how exactly does billing work and are there
any best practices that you've learnedso far with regards to billing as part of that?
And yes, so throughout all of the pharmacies,at most pharmacy,
there's only two as of right now that I'm aware ofthat has patients that are enrolled.
And we've billed for the M3Pso far from what we've seen.
(04:46):
You bill their traditional insurance primary
and then there's going to be an additionalalmost secondary insurance,
but it's a different ID, different group
number, PCN and BIN number for the M3P.
Whenever you initially bill
their primary insurance, if they are enrolled,the way you find out they're enrolled
(05:09):
is you have to go specifically into the claimand see everything that the insurance
has given back to you,which for us in our pharmacy
software is not a normal workflow.
So depending on what kind of pharmacy
softwares are out there, all of you pharmacistslistening are going to have to really work
with them to find the best wayto find out all this information.
(05:33):
But whenever you go into that primary billing
claim, that'swhere you'll see if they're enrolled or not.
And that's where it will give you the ID number,
BIN number, PCN and group numberthat you'll use to build secondary.
That's really interesting.
Rachel.
So essentially you go into thelet me just make sure I'm understanding correctly.
(05:54):
So you go into the primary claim,it gives you the billing information for the M3P,
and then you're billing that informationas a secondary claim for the program.
And so their co-pay after a primary
might be $600 or something along that line.
And then you can go into the claimand see if they are enrolled.
(06:16):
The patient should know if they enrolled or notbecause they should have called and gone
through that process.
And but you'll be able to go into itand then you'll see all of that information.
Put that in secondaryand then their co-pay goes down to zero.
That's very interesting.
So I guess once you figure it out,
that initial part,it seems like it would be fairly straightforward.
(06:37):
It's also very helpful when the patient knowsthat they've enrolled, of course,
but I remember from my experiencepracticing in community pharmacy myself,
not only is the first of the year hecticwith the new plans, deductibles
and everything else, I think this could actuallyadd an additional layer of complexity there.
Just curious from your perspective,how you've kind of navigated
(06:58):
through any hiccups or confusionregarding the M3P?
If there's any kind of pearlsyou can share in terms of the waiting period
that Medicare has put out,
I believe they said roughly 24 hours,but that could be kind of a guideline or any other
just general best practices that you foundto ensure the best customer experience possible.
(07:19):
Yeah.
So in regards to the 24 hour waiting period,I actually had one of my technicians
tell me that she had a co-pay come upthat was really expensive.
She told the patient about it.
He called his insurance and enrolledand that same day
she was able to bill the M3P plan.
(07:40):
So I don't knowif that was just that specific plan
or if there truly is going to be a 24 hourwaiting period for other plans.
But I think you can always try itand see if it works.
And if not, you can just try it the next day.
So the waiting hour, that's just something
that we haven't seen as a hiccup yet
(08:02):
as far as like other confusionsand best practices.
Our company has seven pharmacies and so we do have
strategy callsand talk about what to do every few weeks.
And so I'd really recommend thateven if you're a one store location,
you can still strategize with your currenttechnicians, employees and cashiers.
(08:22):
And so that way everyone's on the same pageand we're telling all of our patients
the same information.
Another thing that some of our locations have doneis within our software,
we can have like a shared taskthat pops up on everyone's login.
And so whenever they figure outthat there's a patient enrolled
(08:43):
in that we've billed for the end M3Pwe'll put it in that shared task.
So that wayany computer on or whenever you're logged in,
they'll be like a little sticky notebasically that says what patients
we have at the pharmacy that are enrolled in that,which is pretty nice.
Another thing that some of our locations
have that we're trying to figure outwith our software, how to make
(09:08):
all of our
locations have is like a triggerthat pops up that any time you just send a claim
through their primary insurance,this little trigger will pop up that says,
hey, they're enrolled in M3P, Soif they're co-pays high make sure you bill that.
So that's been somethingthat we've been trying to do.
So anything that you can put in your softwarethat's basically flagging you, that says that
(09:33):
the patient is enrolled, I think is going to bea huge workflow win when it comes to this program.
Thanks, Rachel, for all of these tipsand kind of best practices
that you've learned here in the first month or soand navigating through these Medicare updates.
This has been really insightfuland I appreciate all that you're doing
on a daily basis to serve your patientsand help them navigate
(09:54):
through these higher than anticipated coststhat they're seeing.
Yeah, of course.
All right.
Well, that's all the time we have here for today.
So I'm going to go aheadand summarize our major takeaways.
First, there's a number of different optionsavailable to patients
who are experiencing higher costsat the beginning of the year here.
So these include the M3P which helpsspread their costs throughout the entire year.
(10:18):
Extra help or patientassistance plans or recommending
a lower cost medicationif one happens to be available.
To bill for a patient through the M3P
it's important to review the primary claimand within the primary claim
that will give you the BIN, PCN an ID for the M3P.
After you've located that,The M3P is then billed as a secondary,
(10:43):
and when you billthat it'll come up with the zero co-pay
in terms of kind of best practicesrelated to that.
And it's certainly important to collaboratewith pharmacists and other team members, both
within your pharmacy and throughout your network,to share those best practices.
As you all know your software better than we do,
(11:03):
but some things that Rachel mentioned
that could potentially be helpfulinclude software enhancements that
perhaps have maybe an automated triggerthat tells staff
this person,a person is enrolled in the M3P bill that plan,
and then they'll come back with a $0 co-pay.
And then you can also in termsof the kind of waiting period,
(11:26):
Rachel has mentioned, that she has some patientsthat the plan becomes active before that period.
So in some cases, depending on the plan,you may be able to build a plan
earlier than 24 hours later and don'tnecessarily have to send your patient away.
All right, folks.
Well, that's all the time we have here for today.
If you haven't listened to part one
(11:46):
of this month's first full podcast yet,it was released just one week ago.
In that episode, I hosted APhA executivefellow Nick and our newest team
member, Maya, and we reviewed detailsrelated to the Medicare updates for 2025.
And these included the new out-of-pocket maxand then details
related to the M3P that we just discussed.
(12:06):
And then as I also mentioned last week,we do have that patient
facing resource availablein the billing center on pharmacies dot com.
So go ahead and head over there.
And it's a nice printable resource
that you can hand to your patientsand use one answering question and last
but certainly not least, pleasedon't forget to head over to the learning library
at learn.pharmacist.comto earn your CE for this month’s podcast.
(12:29):
CE is available for both pharmacistsand pharmacy technicians this month,
so we hope you take advantage of it. Take care.
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