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Drug Reimbursement—Getting it Right is a Team EffortBy Marianne Buehler; Amy DeQuaker; Martha Ewell; Susanne Kluge, RPh; Debbie Newton; Dhruvisha Patel, PharmD; and Roni Wallace

PHARMACISTS AND PHARMACY TECHNICIANSThis INFUSION article is cosponsored by Educational Review Systems (ERS), which is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education. ERS has assigned 1.0 contact hours (0.1 CEU) of continuing education credit to this article. Eligibility to receive continuing education credit for this article begins September 26, 2016 and expires September 26, 2019. The universal activity numbers for this program are 0761-9999-16-267-H04-P and 0761-9999-16-267-H04-T. Activity Type: Knowledge-Based.

NURSESEducational Review Systems is an approved provider of continuing nursing education by the Alabama State Nurses Asso-ciation (ASNA), an accredited approver of continuing nursing education by the American Nurses Credentialing Center, Commission on Accreditation (ANCC). Program #05-115-16-007. Educational Review Systems is also approved for nurs-ing continuing education by the state of California, the state of Florida, and the District of Columbia. This program is approved for 1.0 hours of continuing nursing education. Eligibility to receive continuing education credit for this article begins September 26, 2016 and expires September 26, 2019.

DIETITIANSEducational Review Systems (Provider number ED002) is a Continuing Professional Education (CPE) Accredited Provid-er with the Commission on Dietetic Registration (CDR). Registered dietitians (RDs) and dietetic technicians, registered (DTRs) will receive 1.0 hour or 0.1 continuing professional education unit (CPEU) for completion of this program/ma-terial. Eligibility to receive continuing education credit for this article begins September 26, 2016 and expires September 26, 2019.

Dietitian Knowledge Level: 2 Dietitian Learning Codes:

5030 Home care5440 Enteral and parenteral nutrition support7100 Institution/regulatory policies and procedures, HCFA, OBRA, Joint Commission, NCQA, OSHA, USDA7170 Reimbursement, coverage

Continuing education credit is free to NHIA members, and available to non-members for a processing fee. To apply for nursing or pharmacy continuing education, go to www.nhia.org/CE_Infusion and follow the online instructions.

CPEAccreditedProvider

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Approval as a provider refers to recognition of educational activities only and does not imply Accreditation Council for Pharmacy Education, ERS, or ANCC Commission on Accreditation, approval or endorsement of any product. This Continuing Education Activity is not underwrit-ten or supported by any commercial interests.

This continuing education article is intended for pharmacists, pharmacy technicians, nurses, dietitians, and other alternate-site infusion professionals.

In order to receive credit for this program activity, participants must complete the online post-test and subsequent evaluation questions available at www.nhia.org/CE_Infusion. Participants are allowed two attempts to receive a minimum passing score of 70%.

EDUCATIONAL LEARNING OBJECTIVES1. Comprehend the advantages and disadvantages of billing for home infusion services through the drug benefit. 2. List three factors that affect the final payment a provider can expect when billing for home infusion drugs. 3. Identify three scenarios where the reimbursement and clinical teams can collaborate to solicit a payer exception in coverage.

AUTHOR BIOMarianne Buehler is the EDI Reimbursement Manager for Option Care. She has over 25 years of experience with insurance and reim-bursement, specializing in electronic data interchange and system implementation. Prior to Option Care, in 2005, Buehler was the systems implementer and trainer for several software systems, including CareVoyant, Florida Software Systems, and Crystal Reports. She co-authored an article of ICD-10 preparedness for INFUSION magazine and has presented at several conferences on various reimbursement subjects.  Buehler has a Bachelor’s in Communication, Arts and Sciences from DePauw University.  Amy DeQuaker is the Intake Manager for Option Care in Wood Dale, Illinois. She has over 25 years of insurance and reimbursement expe-rience, specializing in revenue cycle management. DeQuaker has been with Option Care since 2003 and has held multiple roles throughout out her home infusion career, including Reimbursement Manager, Intake and Documentation Supervisor, and Reimbursement Specialist. DeQuaker has extensive knowledge of acute and long-term home infusion therapies and specialty pharmaceuticals.  She also has a strong IT background and worked on the computer conversion at her previous organization and is currently the administrator for Daytech at the Wood Dale, Illinois branch.  DeQuaker has written and implemented many policies and procedures throughout her career and worked to develop standardized best practices for home infusion reimbursement.

Martha Ewell is the Intake Manager for Option Care’s Nebraska offices.  She has over 10 years of insurance and reimbursement experience, specializing in home infusion.  Prior to joining Option Care in 2011, Ewell was a Human Resources Assistant and Insurance Coordinator for Heartland Home Infusion, an HCR Manor Care company operating out of Minneapolis, Minnesota.  Ewell has a Bachelor’s in Journalism, Editing, and Publishing from Wayne State College.

Suzanne Kluge, RPh, is the National Manager of Pharmacy Operations for Option Care in Bannockburn, Illinois. She has more than 20 years of home infusion experience and has been with Walgreens for over 15 years.  During her tenure, Kluge has held several positions including Clinical Pharmacist, Pharmacy Manager, Director of Pharmacy PGY-1 Residency Program, and Area Clinical Director. She has managed clinical operations, trained clinicians, written policies and procedures, and presented in-service training sessions. Kluge is also currently a pharmacy and nursing surveyor for the Accreditation Commission for Health Care (ACHC) and a member of the American Society of Health-System Pharmacists’ Ambulatory Care Specialty Advisory Group for Home Infusion.  She attended St. Louis College of Pharmacy in St. Louis, Missouri and is a preceptor for Ohio State University and University of Colorado Pharmacy School interns as well as PGY-1 pharmacy residents.

Debbie Newton is the Intake Manager for Option Care’s Montana locations.  She has over 35 years of accounting, insurance, and office management experience, specializing in accounts receivable, accounts payable, general ledger, payroll, and human resources. Within Option Care she focuses on intake and reimbursement. Prior to joining Option Care in 2003, she was the Chief Financial Officer for a nursing home; a homeless agency; a family-owned construction company, and an insurance company. 

Dhruvisha Patel, PharmD, is the Director of Pharmacy for Crescent Healthcare, an Option Care company in California. She has worked over 13 years in home IV infusion. She has gained extensive knowledge and experience in both the clinical and management arena. With 36 direct reports that include pharmacists, pharmacy technicians, and warehouse staff, Patel ensures operational efficiency and compliance with the company’s policies and procedures. She has a Doctorate in Pharmacy from Western University of Health Sciences.

Roni Wallace is the Nebraska Billing Center Manager for Option Care. She has over 20 years of insurance and reimbursement experience, specializing in home infusion billing, collecting, and contract knowledge. She has also provided training on specific contract guidelines and requirements for proper billing and collection of home infusion services.

AUTHOR DISCLOSURE STATEMENTThe authors declare no conflicts of interest or financial interest in any product or service mentioned in this program, including grants, em-ployment, gifts, stock holdings, and honoraria.

Questions or comments regarding this article should be directed to marianne.buehler@optioncare.com or 224-206-9859.

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drug codes (NDCs), which identify the drug, dosage, and package of the prescribed therapy.

Billing under the major medical benefit typically re-quires a combination of codes under the Healthcare Com-mon Procedure Coding System (HCPCS). One for the drug (J-codes) and one for the services (S-codes). It’s important to note that J-codes identify the chemical/generic name of the drug, but do not specify the manufacturer, strength, package size, or quantity dispensed. Therefore, several dif-ferent drugs may be represented by one J-code. Medical claims usually require prior authorization and are submit-ted using the CMS-1500/837 format.

There are advantages and disadvantages to each type of claim (see Exhibit 1), so properly determining which path-way to use is a key measure of success. The two most sig-nificant factors are: 1) the reimbursement level compared to your costs, and 2) the best interest of the patient. When considering the patient, variables such as co-pay versus other options (i.e. Can the patient drive to an outpatient center? Are other providers available in their area?) come into play.

When the pathway decision is yours to make, it can of-fer options. But, it’s critical that you weigh the choices and their associated consequences. If you bill in one way and don’t see favorable results, there is, in the immortal words of Jimmy Page and Robert Plant, “still time to change the road you’re on.” It’s possible to switch claims pathways on the next dose, but it’s strongly advised that you investigate how this might affect the patient’s financial responsibility. Moving from the pharmacy benefit to the major medical benefit at the beginning of a plan year, for example, might require a large payment for a patient who has not yet met his or her deductible. Be prepared with suggestions regard-ing payment plans, assistance programs, and other mecha-nisms that might mitigate the effects of an increased out-of-pocket expense.

Know the Contract

It’s important to know the details of your organization’s payer contracts in order to bill for services appropriately. With drug plans and PBMs, we check the drug formularies that spell out which drugs are covered, how the coverage is tiered, and so on.

With major medical coverage, we need to understand the fee schedule, which determines the reimbursement. For drugs, most commercial plans reimburse at average wholesale price (AWP) minus a percentage, or at average sales price (ASP) plus a percentage. There is a veritable alphabet soup of drug reimbursement models being used today (see Exhibit 2), but these two are the most prevalent in our industry.

It’s important to note that most plans—drug and medical—designate their own maximum allowable cost (MAC), which is

Home and specialty infusion therapy are high-touch medical services requiring clinical and operational staff to work collaboratively in delivering high-qual-

ity infusion services to patients at home. However, a signif-icant portion of the reimbursement dollars received are for drugs, not for services. The ratio between overall payment for drug versus services is largely dependent on the com-pany’s payer sources and therapy mix, but with our 100+ years of combined experience in this industry, we estimate that nearly three-quarters of overall accounts receivable (A/R) falls into the drug reimbursement category.

In the big picture, downward pressure on per diems continues to shrink margins and increase the importance of drug payments to A/R. Leaders in the field, and at our organizations, strive to demonstrate the value of home infusion services and fight for adequate reimbursement for all of the components of care in both payer contract-ing and on the policy front. But, while those battles are being fought, our provider organizations rely on good re-imbursement practices to secure and maintain financial health. Getting paid for the services provided requires a team effort.

Determine the Best Pathway

All reimbursement begins in the intake department with a patient referral. The intake team, often the “most valuable player” in reimbursement, must collect a great deal of dis-parate information from a variety of sources—in a hurry. They use this data to make a series of decisions, starting with “is this an appropriate patient to bring on service?” (See “Intake: It’s All in the Start” on p. 29 for more.) From a purely reimbursement standpoint, the objective is to re-view the patient’s insurance coverage to determine what products and/or services the organization is contracted to provide, and capture all available payments.

The next decision pertains to which billing pathway offers the best coverage. With Medicare and most state Medicaid programs, the pathway is predetermined and reimbursement staff members simply follow the program guidelines. Even with many commercial insurance plans, it’s a clear “either-or” scenario, based on the plan’s bene-fit design. However, some plans offer coverage for home infusion therapy under both the major medical and the pharmacy benefit. Although the coverage may appear seamless to the patient, medical and pharmacy benefits are managed by different entities and therefore the claims are processed differently.

Billing for drugs under the pharmacy benefit means working with a drug plan, which typically means billing a pharmacy benefits manager (PBM). Claims are submitted through the National Council for Prescription Drug Pro-grams (NCPDP) electronic pathway, which offers near-im-mediate authorization. Drug card claims require national

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the upper limit that the plan will pay for a given drug. MACs differ based on several factors including market availability and whether or not there is a generic alternative. So, if the AWP- or ASP-based pricing outlined in your contract exceeds the MAC, your reimbursement is capped at the MAC level. Sometimes, the payer will use “lesser than” language, indicating that it will pay for X or Y, whichever is less. Other times, payers will “carve out” specific drugs, typically high-cost biological products such as blood factors, IVIG, and specialty medications, from any of the aforementioned pricing schedules.

All of this means that the reimbursement staff needs to examine several different possible scenarios and compare them to determine the correct billable amount. Based on the prescribed therapy, you should be checking to see if the drug is carved out, looking for a contracted amount, and double-checking that it doesn’t exceed the MAC or isn’t sup-planted by some “lesser than” language to determine what you’ll be paid.

Since reimbursement usually follows the 80-20 rule, our organization typically files the majority of our claims with the same handful of payers. Eventually, we become familiar with their fee structures and are adept at navi-gating each payer’s processes. Then, there are payers we file claims with less frequently. Working with them re-quires more investigative effort during intake and prior to claims submission.

Even when we feel like we’re catching on, it’s important to remain vigilant. There are more health insurance plans now than ever, and patients and employers have more op-

portunity to change plans. In addition, the benefit design, formularies, and other features of the plans themselves are constantly changing. That’s why our standard best prac-tices call for performing an eligibility check before every dose of high-dollar specialty medications, even for long-time patients.

Drug plan formularies also change frequently. Medicare Part D plans, whose formularies can differ from month to month, are the most notable examples. Medicaid formular-ies also change frequently, depending on the rebates each program receives from drug manufacturers. It’s wise to run a test claim before the pharmacy mixes the drug so you know if the coverage is there. Many of our branches run Medicaid claims three times: a test, a reversal, and a real claim. Note that in some states, Texas for example, run-ning multiple claims, even as tests, is increasingly viewed as fraud and may not be a wise practice.

Exhibit 1 Insurance Benefit Comparison

Pros Cons

Major Medical Benefit • Smaller co-pay for patients who have met their deductible

• Usually includes some reimbursement for services and supplies

• Includes a case manager or someone with clinical knowledge on the payer end who can understand home infusion and authorize supplies and services

• Slower reimbursement (typically weeks)• Authorization is not a guarantee of

payment• Carve outs for specific therapies (usually

high-dollar)

Pharmacy Benefit/PBM • Immediate coverage determination • Lower co-pays for patients who haven’t

met their large major medical deductible

• Limited coverage for supplies, pharmacy monitoring, and nursing services

• Higher co-pays for patients on chronic therapies

• No clinical gatekeeper with which to plead your case

• Limited distribution on certain (i.e. specialty) drugs

Exhibit 2 Drug Reference Pricing ModelsAWP – Average Wholesale Price

ASP – Average Sales Price

WAC – Wholesale Acquisition Price

AAC – Average Acquisition Cost

EAC – Estimated Acquisition Cost

MAC – Maximum Allowable Cost

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It’s a challenge to get all the vital information into one place for reimbursement staff to sift through. Most provid-ers load their payer contracts, or the necessary specifics, into their billing software, or onto a shared drive or some other easily accessible file for intake and billing staff to ref-erence. There are a variety of other online tools available to assist in finding current drug pricing and coding informa-tion—many even provide updated drug pricing informa-tion, crosswalks and trending by therapeutic class, as well as some payer-specific information (see Exhibit 3).

Exhibit 3 Reimbursement Coding and Pricing ToolsDrugReimbursement.comOptum360 Codingwww.optum360coding.com/Product/22183/

ReimbursementCodes.comRJ Health Systems www.reimbursementcodes.com

Find-a-Code Comprehensive SearchAmerican Medical Associationwww.findacode.com

Palmetto Drug Lookup and Calculator Toolwww.palmettogba.com/palmetto/mc.nsf/ivr_display?openform

Double Check Drug Codes and Billing Units

Online tools can be helpful for calculating billing units using different drug codes. This is a technical nuance that cannot be overlooked because it directly affects reimburse-ment as well as inventory and other aspects of pharmacy operations. As mentioned earlier, the billing pathway de-termines if a drug is billed using NDC or J-codes. In order to bill effectively, the reimbursement department must make some calculations and translate the prescribed therapy into the correct number of billing units.

For example, the J-code for infliximab (Remicade®, Jans-sen) is J1745, which defines it as 10mg of the drug, or 100 billing units for a 100mg vial. If the pharmacy dispenses a 500mg vial of infliximab and the claim indicates a quantity of 1 on a medical claim, then you will not be paid appro-priately. The pharmacy has to request 50 units (5 x 100mg vials) to get paid for a dose of 500mg.

Issues can also arise when a plan’s formulary only spec-ifies certain codes. For example, many Medicare Part D plans outline coverage for certain, but not all NDCs, for a given drug. Vancomycin is a good example, because most plans only specify a 1g unit. So, when a patient is referred

Where Pharmacy and Reimbursement IntersectAs we’ve pointed out, pharmacy and reimbursement are like two hands that need to know what the other is doing. For this reason, our organization often pulls members of each team together to “huddle” on certain cases at the in-take stage. This way, we can determine which billing path-way is most appropriate, designate any special instructions, and make a plan of action if any special appeals are required for payer approval. Reimbursement staff can also submit test claims prior to dispensing to double-check our under-standing of the coverage and ensure that the claim will be adjudicated as we expect.

Our decision-making process usually begins with the pre-scribed therapy. If it involves a large number of supplies, such as those involved in delivering parenteral nutrition, we want to avoid billing through a drug plan because there’s typically no payment for those items. The IV administration methods that involve the fewest supplies would be IV push and gravity.

Administration isn’t the only variable, however. A cancer patient receiving antibiotics via IV push, for example, could have a vascular access device with multiple lumens. Even though our organization is providing only one therapy, we would still be required to send flushes and supplies to main-tain patency in each lumen, quickly doubling or tripling the supply costs associated with servicing the patient.

Auto injectors of epinephrine (EpiPens®, Mylan) are an-other supply example. The center of recent controversy over their record-breaking cost increases, these life-saving emer-gency injectors are often required supplies for patients re-ceiving blood products or first doses in the home. But, they are not usually covered by drug plans, so the provider cost of supplying them may be captured, to some extent, as part of the per diem payments made on the medical benefit side. If a patient is referred on a therapy that requires an EpiPen®, we need to keep this in mind as we evaluate whether or not the pharmacy billing pathway is practical.

Nursing services are an additional factor. If a patient can be quickly trained to self administer the therapy, and sup-plies are minimal, it makes sense to bill via the drug benefit. But, some patients with drug-only coverage don’t feel com-fortable taking on independent administration. In those cases, we consider the actual regimen to minimize the num-ber of nursing visits. For example, a patient on ceftazidime (Fortaz®, Teligent and Tazicef™, Hospira) would require an IV dose every eight hours. Since it’s not financially feasible to conduct three unpaid nursing visits per day, we would consider using an ambulatory infusion pump—also not bill-able under a drug plan—or consulting with the prescribing physician on an alternative therapy.

Since successful patient outcomes are our primary focus, we want to ensure that whatever regimen is chosen will promote patient compliance. When contacting a patient for monitoring or reordering purposes, we at times discover that he or she has not followed the instructions provided.

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Where Pharmacy and Reimbursement IntersectSometimes an alternate therapy with a more convenient ad-ministration schedule can make the difference, but a change in therapy is almost equivalent to starting again from a re-imbursement standpoint. The prescribing physician would need to approve the change and write new orders and the intake staff would need to request authorization. If the new drug isn’t on the drug plan’s formulary, a physician can sometimes make the case for coverage based on adherence challenges, but that involves documentation and time so it’s best to start the process well before the next dispense date.

Drug Shortages

Drug shortages can limit dispensing choices in the phar-macy, and the clinical and reimbursement teams need to work together to secure coverage while finding a therapy that meets the patient’s clinical needs. For example, 1g vials of vancomycin are sometimes difficult to obtain. However, many payers prefer pharmacies dispense and bill for a sin-gle-dose vial rather than using a bulk vial because they don’t want to process claims with partial billing units. If we can point to the fact that the drug or vial size is on backorder, sometimes we can convince the payer to grant an exemp-tion to either use a larger vial size, which carries a different NDC, or pursue an alternative therapy.

Recently, one of our pharmacy locations in California doc-umented shortages of ceftriaxone (Rocephin®, Genentech) and clinical and reimbursement teams worked together to convince the payer to approve coverage of non-formulary vial sizes to service the patient for the duration of the shortage.

Our pharmacy staff is highly sensitized to payer-specif-ic requirements, and usually conducts strict quality assur-ance checks on orders before compounding for this reason. Members of the pharmacy and reimbursement teams often huddle on orders associated with certain payers to antic-ipate and troubleshoot issues related to vial sizes, billable units, and drug availability.

Formulary and Plan Changes

Even with all the best research and decision making, you can’t just “set and forget” the reimbursement processes. Drug plans, particularly Medicaid plans, can change their formularies, necessitating a new authorization or test claim each time a therapy is dispensed.

One of our pharmacy locations in Illinois recently had a patient who was receiving ertapenem (Invanz®, Merck) for an infection. This specific antibiotic has only one NDC num-ber and no generic equivalent. It was covered under the pa-tient’s Medicaid HMO for the first and second dispense, but the third time we prepared to dispense the drug, we learned that the patient had changed HMOs and the drug was not listed on the new plan’s formulary.

The physician felt strongly that the patient should remain on this particular drug, thus, she began to prepare the doc-umentation to submit a request for an override. But the re-fill needed to be dispensed before the weekend in order to avoid disrupting therapy. In the end, the payer denied the request, asserting there was a cheaper alternative. Because we didn’t know about the plan change sooner, the pharma-cy had no viable option but to continue the therapy and hope for the best on the reimbursement side.

The same type of scenario can happen when a major med-ical plan changes its network of providers. This typically hap-pens annually, but still can take both patient and provider by surprise and have costly ramifications. Imagine having a long-term patient on an expensive orphan drug with limited distri-bution channels, such as Berinert® (CSL Behring) a C1 esterase inhibitor (human), and learning that your organization is no longer a preferred provider for that particular medication? In such an event, the providers are left with limited time and resources to work through transitioning patient care before discontinuing services.  Since most of these medications are medically necessary, and to avoid compromising patient care, pharmacies encounter the risk of non-payment while con-tinuing to dispense for these patients until new providers are established.  To complicate matters even more, many chronic patients like those on Berinert® often rely on patient assistance programs to help with their co-pays, which usually do not take effect until primary insurance claims have been processed and paid.  When providers can no longer bill primary insurers, pa-tients are in jeopardy of losing access to co-pay assistance.

Patient’s Financial Responsibility

Patients can face large co-pays and deductibles, which is an-other important consideration for the reimbursement and pharmacy teams. A common example is when a patient on a brand name antibiotic approaches the donut hole in Medi-care Part D coverage. We recently had a patient who was re-ceiving a four-week regimen of daptomycin (Cubicin®, Merck) for MRSA positive cellulitis of the right lower limb. Over the first two of weeks of therapy, the patient’s co-pays were min-imal. But, by week three, the patient reached the donut hole and the co-pay went up exponentially.  When we informed the patient, he declined the delivery, stating he was unable to afford the higher co-pay. Our pharmacist informed the doctor of the issue and the cause. Despite there being no generic for Cubicin®, the pharmacist and physician conferred and, based on the culture and sensitivity report showing susceptibility of MRSA, the physician decided to switch the patient to vanco-mycin for the remainder of the therapy.

To be sure, our reimbursement department ran a test claim for the new drug through the patient’s Part D plan and the co-pay was indeed much more affordable. As a result, the pa-tient was able to complete the therapy as prescribed.

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with the dose of 1.25g IV every 12 hours and we are dis-pensing a weeks’ worth at a time (14 doses), the pharmacy needs to consider the drug coverage. If the patient’s plan covers a bulk vial (10g vial size), the pharmacy can pull two 10g vials and bill partial vials. But, if the plan specifies a 1g vial size, they will need to pull 18 1g vials.

To get this right, you have to communicate with the clin-ical team as the patient is coming on service—not when the claim is being prepared for submission. In our organi-zation, we usually indicate special instructions like these on the compounding sheet, making a note to use a specific NDC for that patient.

Communication with Clinical Staff is Key

There are other good reasons to keep open the lines of communication with the clinical side of your organization. If a drug has a low MAC, for example, we work with our clinical staff to explore other options, such as administra-tion via IV push, that will allow us to treat the patient with-out taking a loss.

Depending on the class of drug and the patient’s condition, it might be possible to change the prescribed therapy to one that’s covered. This is a clinical judgment made by the referring physician, but reimbursement information can factor into the decision making. We usually have a nurse liaison at the hospi-

tal who works through these scenarios with the physician and the discharge planners before the referral is made. Together, they will explore options based on the patient’s insurance plan and sometimes the clinical team is willing to adjust the ther-apy or regimen based on coverage; other times there’s only one way to treat the patient and we do our best to convince the payer to make an exception if the coverage isn’t there. It’s these cases that underscore how critical the intake piece is to the entire reimbursement puzzle. See “Where Pharmacy and Reimbursement Intersect” on p. 38 for more examples of clin-ical and reimbursement teams working together.

Perhaps our most significant, ongoing challenge is work-ing with payers so they understand home infusion therapy. Many payers, or their representatives at the authorization and claims resolution levels, don’t understand our lan-guage. We often find ourselves explaining how the service works in order to justify receiving reimbursement for sup-plies and services. For example, some plans have a specialty drug component where infusion drugs, such as infliximab (Remicade®, Janssen) or natalizumab (Tysabri®, Biogen), are carved out. The payer sometimes expects these therapies to be treated like oral and self-injectable specialty drugs that are shipped directly to the patient from a mail order pharmacy. We need to explain how the drug is adminis-tered and why services and supplies are required. It’s of-ten helpful to have someone from our clinical team talk

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through the details with the payer’s case manager, who is usually a nurse and can understand the implications.

With major medical plans, we are often granted an ex-ception and can take the patient on service with the confi-dence that our claims will be processed and paid. However, we don’t typically succeed in convincing drug card plans to vary from their strict coverage guidelines. At that point, we have to decide if we’ll provide the therapy without any reimbursement for the drug.

Collect from the Patient

No provider can afford to be less than vigilant in calculat-ing and collecting the patient portion of reimbursement for services. Health plans are shifting more financial responsi-bility to patients which means that their portion of total reimbursement is growing.

To figure out the patient’s financial responsibility for care, you must know the plan’s deductible, co-pay, and out-of-pocket limits. This can be tricky because these amounts are difficult to accurately predict before the claims are processed. For example, the amount the patient has paid towards his or her deductible can change in the time be-tween intake and claim processing, which could lower the amount he or she owes you. On the other hand, a new plan year could begin, restarting the deductible, and greatly in-creasing the patient’s responsibility.

For these reasons, we always tell the patient that our figures are based on information provided “today” and are only an estimate. We often investigate drug discount plans, patient assistance programs, and other possibilities to have helpful information on hand when speaking to a patient.

Train, Train, Train

It takes a great deal of trial and error to gain a strong un-derstanding of the different reimbursement pathways, pay-ers, benefit designs, and other fundamentals involved in submitting claims—and in avoiding denials (see “Why, Oh Why Did My Claim Deny?” on p. 22 for more on manag-ing denials). Because the learning curve is so steep and the considerations change so rapidly, our organization perpet-ually trains and uses many reference tools to support our day-to-day processes.

We store a multitude of informational materials on a shared drive for reference: copies of fee schedules, job aids, sample insurance cards, and links to insurance company and state Medicaid websites where policies and instruc-tions can be found. We also do “brain shark” training, de-signed to teach new reimbursement personnel which staff veterans to rely on for expert advice.

For new intake personnel, we create checklists of ques-tions to ask when verifying benefits, and we coach them on how to talk to insurance company representatives to get the real answers they need.

With so many moving parts, home infusion reimburse-ment can be challenging, but also rewarding. Through diligence and collaboration, poroviders can improve their chances of getting paid for the care that has been pre-scribed. And in today’s market, that means fully under-standing the ins and outs of drug coverage and claiming, and communicating effectively with the clinical team so they can plan for appropriate care for each patient.