In the past few years, healthcare systems and patients have recognized the value of reducing hospital visits and exposure to infectious diseases by managing therapies at home. In the home infusion setting, this led to the growing use of subcutaneous delivery of biotherapies as an alternative to IV administration. Although subcutaneous formulations were first introduced in Europe in 2014, the COVID-19 pandemic highlighted and accelerated efforts to allow patients to administer drugs with limited contact. The top therapies commonly used in home infusion when transitioning from IV to subcutaneous routes of administration include rheumatology, neurology, oncology, and endocrinology.
Subcutaneous products have shown to be more cost-effective while improving the patient’s experience in managing chronic and complex conditions outside of traditional healthcare facilities. Subcutaneous products are minimally invasive for the patient. Conversely, the IV route, especially with elderly, can be significantly more invasive and reported to cause more emotional distress. For those patients who have a difficult time traveling or live far from a hospital setting, subcutaneous products have also been effective in managing their conditions and relieving their anxiety in coordinating travel.
From a pharmacy provider’s perspective, acquisition costs for IV infusions and subcutaneous products are similar. However, subcutaneous products are considerably less of a financial cost when considering potential waste from compounding drugs for IV infusions as opposed to predetermined subcutaneous injections. With increased patient demand and an overall financial benefit to pharmacies, there has been a surge in practices billing claims for subcutaneous products in the home infusion setting.
However, many providers are facing difficulties in billing for subcutaneous products in the home infusion setting, as it differs from traditional IV billing processes. IV-administered drugs typically fall under the health plan medical benefit and use the HCPC coding system, as opposed to PBM billing and processing. There could be four to six weeks waiting time in knowing if that claim will be processed before understanding if that claim with be paid or ultimately denied. Conversely, most subcutaneous products, especially self-administered injections, fall under the PBM billing system, which is associated with a quicker turnaround time for reimbursement.
If a patient is switching from IV to subcutaneous therapy, even if it is the same drug, there are still several differences in benefits, coding, and billing of this change in therapy. Some examples of what home infusion providers need to particularly focus on when billing these changes in therapies include: coverage or authorization changes, type of therapy, and whether there are any payor specific guidelines. From a billing perspective, providers should be aware of the Medicare benefits, especially Medicare Advantage Plans, and anything that follows these guidelines, as well as modifiers attached to identify how that drug is being administered for the proper reimbursement. For example, Medicare requires that drugs that can be administered both IV and Subcutaneous will need to be identified on the claim with the appropriate modifier. If drugs are billed without the appropriate modifier, those claims will be denied. It is vital to be very specific with coding and modifiers when applicable to ensure the claims are processed without delay.
Insurance companies may reject claims due to alleged coding errors, even when the services provided are medically necessary and appropriately documented. This tactic can result in delays in payment and additional administrative burdens for pharmacies. Also, Insurance companies may intentionally delay processing and payment of claims, often citing internal review processes or system issues. These delays can strain pharmacy finances and disrupt cash flow, impacting their ability to purchase medications and supplies.
Home Infusion Providers can actively get ahead of operational changes to ensure their billing process is smooth for both them and their patients. These changes can encompass several key areas, including the application of the latest clinical guidelines, modifications to treatment plans, adjustments to operational workflows, and updates to intake and referral processes. Additionally, strategies for reimbursement may need to be reevaluated to align with evolving care models. Enhancing communication is a critical component, involving improved coordination within the internal care team, better collaboration with external care teams, and more effective engagement with patients and their caregivers.
How Frier Levitt Can Help
Pharmacies can mitigate the impact of tactics used by insurance companies to delay or deny payments by discussing with an attorney about how their practice may leverage applicable state and federal laws and regulations to ensure they receive full compensation for services. Litigating payor-provider disputes has become a necessary and effective way to ensure not only that home infusion providers are properly compensated, but also that their patients get the best level of care and benefits to which they are entitled.
Frier Levitt has experience helping practices effectively and accurately bill for both IV and subcutaneous drug administration. Our experienced healthcare and life sciences attorneys can guide your practice in addressing patient insurance coverages hurdles, medication and supply shortages, technology constraints, proper billing practices, how it affects patients, and ensuring compliance with applicable laws. If you have questions or would like to discuss further, contact us to speak to an attorney.
