3 Things You Need to Know about Pharmacy MTM and Star Ratings

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Aug 4, 2016 8:00:00 AM

Pharmacy MTM counseling session

Medication Therapy Management (MTM) is not necessarily a new topic in the pharmacy world. Well before pharmacists were being reimbursed for their time, they were counseling patients on their medication regimens, options for alternative treatment, and other options to consider.

In the last decade this type of service has become a requirement for independent pharmacies. Starting with Medicare Part D patients, many plans and payers have adopted MTM services as a requirement. To enforce this practice and ensure the health of their star ratings, insurance providers and PBMs have begun to evaluate health care providers, such as pharmacies and prescribers, on their service. This evaluation can have a big impact on the pharmacy business.

PBM control over reimbursements is already an area where independent pharmacies struggle, so anything you can do to gain favor with them can only be good for your business. To help you along, here are three things to know about pharmacy MTM and its effect on your business.

It’s not just how well you do it, it’s that you do it.

MTM is not the only aspect of your business that is evaluated – adherence and medication safety are also taken into account. When evaluating your pharmacy’s MTM offering, PBMs look at the percentage of cases completed based on the number of patients deemed eligible for MTM.

It’s not feasible for the PBM to review the cases and your complete CMR and rate you based on the quality of counsel you performed. Therefore, they must turn to quantitative data. This means that whether a counseling session takes you fifteen minutes or an hour, it is still a case completed.

Please don’t think that I’m telling you to cut corners in your counseling sessions. Ensuring that your patients are on the best possible regimen for their condition is very important. However, there are things that you and your staff can do on a regular basis that may help make your CMR a smooth process. (We’ll talk about these in section 3)

The healthy response of your patient to your MTM services is crucial and is the ultimate goal for all invested parties.

You can bill insurance for your services.

Offering MTM services is not a one way street as it used to be. You can now also benefit. If plans feel that your pharmacy could be a detriment to their star rating, plans can choose to rework their system to exclude you from their network or even charge penalty fees. This is obviously undesirable, since you will likely lose patients and revenue. However, if you are offering services that impact their star rating positively, plans may offer incentives or send more patients your way as a way of “helping you help themselves.”

Additionally, you can bill plans for your time. There are universal codes for these services. They allow you to bill for initial meetings and additional time spent with each patient. It’s possible there will be more to come in the future for prep work done before actually meeting with the patient.

Your pharmacy management software should be able to help you.

Your pharmacy software may interface with third party companies, such as Outcomes and Mirixa, which will notify you when a patient is eligible for MTM and other MTM opportunities that may not be with your current patients. For current patients, viewing their case could be as easy as a click of a button during the dispensing process.

You may wonder why you would want to know about MTM cases that aren’t for your current patients. Contacting potential customers about their medication regimen, shows that you are a knowledgeable and caring health care professional. One that offers services they’re not receiving from their current pharmacy. Not only does it increase your reach in your community, but it creates an opportunity to expand your pharmacy’s business.

In addition to third-party interfaces, your pharmacy software may have a place to record your own patient MTM information. This is where you can streamline the CMR process. When interacting with a customer ask routine questions that may come up in a counseling session and record their information. This allows you to keep a record of critical information, such as blood pressure, adherence data, and vaccinations, that can be used when the patient comes up for MTM counseling.


Over the last decade the clinical aspect of independent pharmacy has grown immensely, putting more responsibility on you and your staff. This has allowed many small pharmacy owners to compete with the larger chain retailers that don’t offer the same personal care that you’re able to give your patients. Use the knowledge gained here to embrace this practice to the advantage of your pharmacy business.

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