Home infusion pharmacies serve as a vital bridge between traditional healthcare settings and patients’ homes, offering a myriad of benefits that significantly enhance patient care. Firstly, it provides a lifeline for individuals with chronic conditions or complex medical needs, enabling them to receive specialized medications and therapies in the comfort and familiarity of their own environment. This not only improves patient comfort and convenience but also promotes better adherence to treatment regimens, ultimately leading to improved health outcomes. Moreover, home infusion pharmacies reduce the burden on hospitals and healthcare facilities by shifting care to less costly settings, thereby alleviating strain on healthcare resources and allowing hospitals to focus on acute care needs.
Additionally, home infusion pharmacies play a pivotal role in empowering patients to take control of their health journey. By receiving treatment at home, patients gain greater autonomy over their healthcare decisions and experience a sense of independence that fosters emotional well-being. Furthermore, home infusion therapy often involves close collaboration between patients, caregivers, and healthcare providers, fostering stronger bonds and promoting personalized care tailored to individual needs. This collaborative approach not only enhances patient satisfaction but also facilitates continuous monitoring and adjustment of treatment plans, ensuring optimal outcomes over the long term. In essence, home infusion pharmacy represents a cornerstone of patient-centered care, combining clinical excellence with compassion to enrich the lives of those in need.
Unfortunately, we have found that Home Infusion Providers are having trouble providing services to patients. Providers are struggling with unwarranted network exclusions and non-payment issues.
Network Exclusions
Network exclusion for home infusion pharmacies can have significant implications for both patients and pharmacies alike. From the perspective of home infusion pharmacies, network exclusion can limit their ability to serve patients who rely on their specialized services. Being excluded from a network can result in decreased patient referrals and access to a smaller pool of potential customers, ultimately impacting the financial viability of the pharmacy. Moreover, network exclusion may lead to increased administrative burdens and reduced bargaining power when negotiating reimbursement rates with payers, further straining the pharmacy’s operations.
For patients, network exclusion can translate to limited choice and reduced access to the specialized care provided by home infusion pharmacies. Patients may be forced to seek services from unfamiliar or less experienced providers, potentially compromising the quality and continuity of their care. Additionally, patients may face higher out-of-pocket costs if they choose to receive care from an out-of-network provider, further exacerbating financial burdens associated with their medical treatment.
Payment Issues
Even when admitted into Networks, Insurance companies may use various tactics to delay or deny payments to home infusion pharmacies, impacting their financial stability and ability to provide essential services. Some common tactics include:
- Claim Denials: Insurance companies may deny claims submitted by pharmacies, citing reasons such as incomplete or inaccurate information, lack of preauthorization, or failure to meet specific coverage criteria.
- Coding Errors: 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.
- Delayed Payments: 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.
- Utilization Management: Insurance companies may implement utilization management strategies, such as formulary restrictions or quantity limits, which can lead to claim denials or reduced reimbursement rates for pharmacies.
- Contractual Disputes: Insurance companies may dispute claims based on contractual disagreements, such as disputes over reimbursement rates or coverage terms. Resolving these disputes can be time-consuming and costly for pharmacies.
How Frier Levitt Can Help
There are tools and strategies available to combat network exclusions, ensuring patients have access to the care they need and to support the viability of specialized healthcare providers. Both Federal and State laws, such as Any Willing Provider Laws, can be leveraged to develop strategies to address network lock outs for certain drugs/payors, including self-insured plans. Additionally, having a familiarity with each network can aid in seeking access to networks.
Additionally, 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 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.
