Infusion Centers Must Be Proactive to Reduce Risks

Therapies delivered via infusion are a critical part of the care for chronically ill patients across the country. However, providing infusion therapy in a practice can create a high level of risk from a payer standpoint, as reimbursement for these services is complex.

Practices providing infusion therapy must be mindful that at some point, they will be subject to various audits and scrutiny from CMS and commercial payers. Consequently, when establishing a practice infusion center, its foundation must be built on tenants of compliance and governance and instilled with a level of ongoing vigilance.

Infusion therapies fall under the scope of CMS’ Fraud, Waste & Abuse (FWA) program, an aggressive effort by CMS to protect the integrity of Medicare across the health care landscape. Every component of care in all types of therapy is being examined, and rightfully so.

CMS is constantly trying to ensure everything is done in a safe, compliant manner, from administration of the therapy to proper dosage, to all aspects of how the therapy is billed. Although there is no precise measure of health care fraud, waste and abuse, exploitation of programs such as Medicare does occur, costing taxpayers billions of dollars while putting beneficiaries’ health at risk.¹

By taking a close look at the major risks infusion practices face, practices can gain insight into how the possibility of negative outcomes can be reduced when threats are encountered.

Risks can be minimized with careful preparation

There are several key areas of risk that infusion practices are likely to face at some point, and proactively preparing for these events can help ensure a positive outcome:

Payer audits

Commercial payers and CMS have coverage rules for various therapies, and it is incumbent upon providers to educate themselves and understand these rules. Payers publish this information, but it is still difficult to stay abreast of the rules, as they constantly change. Payers are continually examining data over time and adjusting their policies, creating an evolving landscape.

Practices must be rigorous around making sure they understand current rules. A maintenance program should be established, and at least twice a year, staff should investigate whether any rules have changed.

Both CMS and commercial payers offer subscription services to keep practices informed about rule changes, for which practices should sign up. Those not subscribing to updates should seek out the information on their own to stay current with any changes. Once gathered, the information should be shared with everyone who plays a role in infusion therapy, from administration to billing, as they all need to understand the rules.

Do not be surprised when an audit happens, as this is the new normal in health care. Rather than being shocked and alarmed, be ready and prepared so the practice can respond quickly.

A timely response goes a long way in the eyes of the auditor, demonstrating everything has been done in a compliant manner. This puts the practice in a position to receive a favorable outcome.

Payer and specialty pharmacy mandates

Commercial payers continually try to reduce health care costs with new edits or mandates that prohibit certain therapies from being dispensed in-practice, instead requiring prescriptions to go to specialty pharmacies that have pricing agreements with them. Unfortunately, these mandates are often implemented with no thought to compliance.

Some mandates require patients to go from conveniently getting therapy in-practice to traveling a hundred miles away. Mandate exemptions can be requested based on various concerns, such as geographic distance or health-related issues. Payers will consider a legitimate request to help with compliance, however, any hint of revenue consideration for the practice will result in denial.

The practice should have a good intake process that early on determines the patient’s benefit eligibility and whether any mandates apply. This provides the best opportunity to design an effective exemption request without delaying care. Payers often grant an exemption when the request demonstrates the patient’s health could otherwise be compromised.

Impacts of health care consolidation

Consolidation has been a worrisome trend in health care for many years. When a provider with infusion services is absorbed by another provider, a focused effort is needed to educate the acquiring group about the value proposition of infusion services to patient care. Often when consolidation is occurring, the details are unclear, and infusion programs may be lost in the shuffle.

From a payer to provider standpoint, payer consolidations can impact specialty pharmacy mandates. Providers must be proactive to gain an understanding of the new rules being established through the consolidation and be ready to present appeals for patients to remain in-practice.

Outside expertise can reduce risks

Because infusion is such a complex process, many practices face challenges running an infusion center without incurring risks to the practice or impacting care in other areas. Consequently, management services specializing in infusion are becoming more prevalent.

One such firm is Intrafusion by McKesson, the organization I work for that provides infusion management services to many neurology, rheumatology, and gastroenterology practices. Services such as this can manage business risks to practices while enabling them to offer infusion services within their practice.

Forethought and planning are critical

The rising cost of health care and industry consolidation have led to payer policies and mandates that create a riskier financial environment for practices to navigate. This is especially true for those with infusion centers, due to the complicated and expensive nature of the services rendered.

Risk will always be a part of delivering care, but certain risks can be anticipated, enabling practices to prepare for them. Infusion centers can reduce their risks by proactively identifying potential threats and developing solutions, such as patient intake form processes, electronic medical record system safeguards, and clinical standard operating procedures, in advance.

Thus, it is important that providers remain informed of changes within their communities, from commercial payers and CMS. You can stay informed by subscribing to any offered notification services, attending educational webinars and conferences, and by building relationships with provider education teams.

Additionally, employing outside experts in critical areas where expertise within the practice may be lacking can minimize risks. Making risk reduction a priority can help ensure the long-term viability of the practice, as well as the continuation of infusion services that are a vital component of comprehensive, patient-focused care.

About the Author

Andres Moreno, VP of Revenue Cycle Operations, Intrafusion by McKesson.

Reference

1. Medicare Fraud & Abuse: Prevent, Detect, Report. The Medicare Learning Network. January 2021. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud-Abuse-MLN4649244.pdf. Accessed June 22, 2022.