Many infusion therapies require insurance preauthorization. DO NOT SKIP THIS STEP, or else you risk not getting paid.
Understand “buy-and-bill.” This is the most common format for acquiring and paying for infusion therapies. In buy-and-bill systems, you, the clinician, are responsible for paying for drugs up-front and then waiting for reimbursement. You will need to build those costs into your financial plan. Most pharmacy wholesalers, distributors, and specialty pharmacies use the buy-and-bill payment system, so you will need to have funds available to set up a purchasing account.
Patients also benefit from “buy-and-bill” as they may not incur the pharmacy benefit costs (ie, third party costs) or all of the major medical expenses sustained when receiving an infusion as part of a hospital’s outpatient services (ie, there typically is no facility fee that is passed on to the patient). This results in cost-savings not only for the patient, but for the healthcare system overall, as insurers are also not responsible for facility fees when infusions are delivered in an independent physician practice setting. In today’s economic climate, it may make more sense for independent clinicians to take on some of the responsibilities typically handled by hospitals as long as there is no compromise in care delivery and if the price of healthcare can be lowered.
What else does buy-and-bill require? As a clinician, you are typically responsible for several aspects of a buy-and-bill scenario.
- Managing inventory
- Administering the drug
- Submitting claims for both the reimbursement of the drug and for related professional services
What are Medicare’s reimbursement policies? Medicare typically reimburses providers at the Average Sales Price (ASP) + 6%, or the Wholesale Acquisition Cost (WAC) + 6%
- Private payers may choose to follow Medicare mandates or set their own pricing, so build these multiple price points into your overall financial plan.
Josh Jacobs, MD
Allergy & Asthma Medical Group of the Bay Area
Greg Bensch, MD
Allergy Immunology and Asthma Group