Reimbursement FAQs
Some commonly held misunderstandings about reimbursement are clarified.
- By BSTQ Staff
Where can one find the current reimbursement rates for infliximab and other infusion medications used to treat Crohn’s disease and ulcerative colitis?
Reimbursement rates vary by health plan and benefit level. The rates also are determined based on claims coding and individual medical necessity. Patients seeking reimbursement rates should contact the individual responsible for reimbursement at either their physician’s office ortheirspecialty pharmacy provider. Physicians can determine reimbursement rates by first locating the average wholesale price or average sales price and then calculating specific rates according to the contracts they accept. Medicare publishes its rates quarterly; they can be found at www.cms.gov/McrPartBDrugAvgSalesPrice. More detailed information on coding and billing for infliximab can be found at http://www.janssenaccessone.com/pages/ remicade/guide/reimbursement/reim bursement.jsp.
How does reimbursement best work in an outpatient/ nonhospital infusion center environment?
The answer to this question depends onwho owns and operatesthe outpatient infusion center. If it is physician-owned, reimbursement is similar to that of an office visit. If the center is owned by a home infusion or specialty pharmacy provider, and their contract with a payer allows for patients to be seen in such a setting, it will work as if the patient were seen at home. Providers should be able to give specific coverage information to patients before services are provided. In both instances, it is important for patients to know that it is their right to understand coverage prior to receiving services. There should never be any surprises concerning amounts owed. Most accredited providers also ask patients to sign a financial consent form,which outlines coverage and who is responsible for paying what, before they receive care.
What can an individual do when he or she has been denied insurance coverage for immune globulin (IG) after his or her employer changes carriers?
Many commercial insurers have focused on decreasing payment for and restricting provision of IG for the last few years due to the high cost of the therapy. There are federal regulations regarding the right to appeal a coverage decision. Each state has additional regulations for appeals.
If denied coverage for IG, an individual should work with his or her physician and IG provider to appeal the denial. The appeal will need to build a case for coverage specifically based on the medical coverage criteria outlined by the carrier. The physician should have visit notes detailing the individual’s progress and improvement on therapy. And, the IG provider should have nursing notes or other documents supporting improvement on therapy. Both the IG provider and/or the physician should be able to assist in writing a letter of appeal, which should outline the condition the individual has, the history and/or progression of disease, specific symptoms or issues experienced when not receiving IG, and objective improvement attained while on IG therapy. Additionally, if the physician has ever tried titrating dose or frequency of infusions, this should be noted in the appeal letter as well.
Editor’s Note: The content of this column isintended to provide a general guide to the subject matter. Specialist advice should be sought about yourspecific circumstances.