For individuals with chronic illnesses or complex medical conditions, home infusion pharmacies make it possible to receive specialized medications in a comfortable, familiar setting. Beyond clinical benefits, home infusion pharmacies empower patients by fostering independence and engagement in their own healthcare. Receiving treatment at home allows patients to maintain a greater sense of autonomy, which can positively impact emotional well-being. These services also encourage close collaboration between patients, caregivers, and healthcare providers, ensuring that treatment plans are closely monitored and adapted to individual needs.
Despite these advantages, home infusion providers face significant challenges that hinder their ability to serve patients effectively. Two primary obstacles include unwarranted insurance network exclusions and payment delays, both of which threaten patient access and long-term viability of these essential services.
Network Exclusions: Unfair Barriers to Patient Access
Being excluded from insurance networks creates significant challenges for home infusion pharmacies, restricting their ability to reach and care for patients who rely on their care. Network exclusion can drastically reduce patient referrals, shrinking the customer base and threatening financial stability. Additionally, it creates significant challenges for independent pharmacies to compete with payer-owned or affiliate pharmacies, many of whom have guaranteed participation in payer networks.
To address network exclusions, providers can:
- Engage in Proactive Negotiations: Pharmacies should advocate for their inclusion in insurance networks by demonstrating their value in improving patient outcomes and reducing overall healthcare costs.
- Leverage Legal Protections: Laws such as “any willing provider” statutes can help combat unfair exclusion practices, ensuring fair access to networks. Over twenty-six states have some form of an Any Willing Provider Law (AWPL), providing protection with respect to certain commercial plans. At a federal level, the Medicare AWPL requires Part D prescription drug plans to “permit the participation of any pharmacy that meets the terms and conditions under the plan.” 42 U.S.C. §1395w-104(b)(1)(A). What’s more, a Part D plan must agree to have “a standard contract with reasonable and relevant terms and conditions of participation whereby any willing pharmacy may access the standard contract as a network pharmacy,” which CMS states extends to “reasonable and relevant reimbursement terms for all Part D drugs.”
- Mobilize Patient Support: Encouraging patients and prescribers to voice their need for continued access to home infusion services can influence payers to reconsider network exclusion policies.
Payment Challenges: Disruption to Care and Cash Flow
Even when home infusion providers can gain admission into insurance networks, home infusion pharmacies frequently encounter a myriad reimbursement and payment challenges. Insurers often use various strategies to delay payment, issue underpayments or reject payments, altogether. Some common issues include:
- Claim Denials: Insurers frequently reject claims due to minor administrative errors, missing prior authorizations, or other technicalities, even when services are medically necessary.
- Coding Disputes: Alleged coding inaccuracies may be used as justification for rejecting claims, causing delays and requiring additional administrative effort to resolve.
- Plan “Finger Pointing”: Issues have arisen when a patient has benefits that have been issued by an out-of-state health plan, and sees a pharmacy located in his or her home state. This has led certain plans – including “Blue” plans – to engage in disputes over which plan is responsible for payment of the claims, with “Blue” plans pointing fingers at one another.
- Delayed Reimbursements: Insurers may intentionally postpone payments, not pay, grossly underpay, or issue payments directly to patients instead of pharmacy citing internal processes or system issues, which can disrupt a pharmacy’s cash flow and ability to acquire necessary medications. Reimbursement is often late, underpaid or not paid at all under the guise of not meeting the required billing for service (e.g., “the medical documentation does not meet the required elements for billing the service”; “the information submitted does not contain sufficient detail to support all charges billed”; “the medical records submitted do not include a physician’s order”; or “medical records do not include a current order for home health nursing service for the billed date of service”).Utilization Restrictions: Insurance companies impose formulary limitations, quantity restrictions, or other measures that reduce reimbursement rates or deny claims outright.
- Contractual Disputes: Disagreements over payment terms or reimbursement rates can lead to prolonged conflicts, further complicating financial sustainability for providers.
To mitigate these challenges, home infusion providers can:
- Implement Strong Billing Practices: Ensuring meticulous documentation and adherence to billing protocols reduces the risk of claim denials. Patients, payers, and providers see the home as a viable alternative to more costly standard of care. As a result, reimbursement for home infusion services has expanded in recent years to better address the needs of patients who would benefit from home infusion therapy (HIT). The introduction of the Medicare FFS HIT benefit begins to fill in the previous gap for coverage and payment of infusion services when DME-covered IV pumps and drugs are administered at home. However, it is not a complete solution for all home infusion therapy. This industry is continuing to grow as more therapies are approved, and patients have positive outcomes at home. Understanding reimbursement for home infusion services will be imperative as there are many factors that affect coverage and access.
- Utilize Appeals Processes and Legal Protections: Pharmacies should challenge unfair denials through structured appeals to ensure proper reimbursement. Laws such as prompt payment statutes, minimum reimbursement laws, MAC appeal laws, anti-patient steering, unfair competition laws, and contract enforcement measures can help providers secure timely and appropriate payments. Some states prohibit below acquisition cost reimbursement or provide unique reimbursement appeal processes. Additionally, Federal law prohibits unreasonable low reimbursement rates for all Medicare Part D drugs. CMS guidance provides, “[o]ffering pharmacies unreasonably low reimbursement rates for certain ‘specialty’ drugs may not be used to subvert the convenient access standards. In other words, Part D sponsors must offer reasonable and relevant reimbursement terms for all Part D drugs as required by [the Medicare AWPL].”[1] So, it is vital to utilize the dispute process in each PBM payor contracts to initiate disputes and explore initiating arbitration/litigation.
In conclusion, home infusion pharmacies provide indispensable healthcare services, yet they continue to face systemic barriers that threaten their ability to operate effectively. By addressing network exclusion issues and advocating for fair payment practices, providers can work toward sustaining these critical services while ensuring that patients receive the high-quality, accessible care they deserve.
How Frier Levitt Can Help
Frier Levitt supports home infusion pharmacies in addressing both network access and reimbursement challenges. Our attorneys are deeply familiar with federal and state laws, such as Any Willing Provider statutes and prompt payment laws that can be used to:
- Challenge unlawful network exclusions
- Advocate for access to restricted drugs or self-insured plans
- Ensure proper reimbursement for services rendered
- Litigate payor-provider disputes when necessary
We work with clients nationwide to protect the viability of their operations and preserve patient access to high-quality home infusion care. Likewise, pharmacies can mitigate the impact of tactics used by insurance companies to delay or deny payments by leveraging applicable state and federal laws and regulations to ensure they receive full compensation for services. Unfortunately, litigating payor-provider disputes has become a necessary and effective way to ensure that home infusion providers are properly compensated, and competent legal counsel can help.
Frier Levitt represents home infusion providers across the U.S. in challenging abusive payor reimbursement practices as well as network access issues. Our attorneys have extensive knowledge of provider-payor relationships and the tactics employed by payors to underpay or refuse to pay home infusion providers for their services. They possess a familiarity with each network and can aid in seeking access to networks, and if necessary, litigating payor-provider disputes. Contact us to speak with an attorney about how your practice may leverage applicable state and federal laws and regulations to ensure you receive the full compensation that you deserve for your services.
[1] Medicare Prescription Drug Benefit Manual, Chapter 5, Section 50.3.
