Inside the Back Office

Inventory tracking, billing, coding and reimbursement are all inextricably linked when a practice delivers anti-VEGF therapy.

One of the advantages of practicing at a large institution is the availability of certain technology that might not be cost effective for smaller practices. Such is the case at the Cole Eye Institute, Cleveland Clinic, where ranibizumab (Lucentis, Genentech) is dispensed and managed via an automated system. "It's an expensive drug," says Peter K. Kaiser, MD, who practices at the Cole Eye Institute. "You need to track it, keep it under lock and key, and make sure you have enough at all times. This is difficult without an automated system."

The computerized drug-dispensing unit (Pyxsis; CareFusion, San Diego, Calif.) at the Cleveland Clinic is secure — a fingerprint is required to open it — and it registers the name of the patient, the medication that was dispensed and the billing numbers. The computer interfaces with the main pharmacy so that when inventory drops below a certain level, it generates a restocking order similar to a just-in-time inventory system.

"An automated drug delivery system may not be practical for most practices," Dr. Kaiser says, "but even a small practice has to have an excellent, dedicated billing person, someone who ensures that all supporting documentation is submitted and keeps track of who paid, who did not pay and why."

ACCOUNTABILITY

At Vitreous-Retina-Macula Consultants of New York, a billing manual — made up of color-coded information sheets and a system of checks and balances — underpins a practice-wide effort to manage ranibizumab inventory and ensure proper billing and reimbursement.

"The first thing we did was buy a locking refrigerator," Dr. Slakter says. "The second thing we did was establish an accountability process, and the first level of accountability is the physician. When I order a treatment, one of my responsibilities is to make sure I've circled the correct diagnosis code on our billing sheet, which indicates the drug I'll use, the associated diagnosis and which eye I'll treat. The first thing the person in the treatment area does is check the billing form. If any information is missing, they bring the sheet back to me. Nothing happens until I complete that part."

According to General Manager Hildy Abel, one key to the system is that access to the refrigerator is limited to two people, and inventory is taken every morning and night. "In 4 years, I'm proud to say we've not lost a vial," she says.

At Retina Consultants of Houston, two new positions were created to help manage the financial aspects of delivering anti-VEGF therapy. One person is responsible for drug accountability, and another handles reimbursement issues for ranibizumab. "With seven clinics, it's important for us to closely monitor our inventory to ensure that we have the correct number of vials at each location," says David M. Brown, MD. "If you don't have drug for a patient when you need it, that's a terrible inconvenience. On the other hand, if you administer a drug and don't bill for it, that can be catastrophic in terms of financial implications. So you want to make sure you know where the drug vials are going."

To help manage inventory and ensure proper billing, Dr. Brown and some of his colleagues are working on a bar-code system to track ranibizumab by patient but the system is still under development. Dr. Brown says, "You need a very diligent person with a spreadsheet or some other method for tracking when drug was received, when it was used and for whom, if it was billed and so on. Fortunately, we have such a person assigned to drug accountability."

CODING AND REIMBURSEMENT

For Medicare patients receiving anti-VEGF therapy for an approved indication, receiving reimbursement for treatment is usually straightforward. "The coding is fairly simple," Ms. Abel says. "Our billers are well educated in all codes and modifiers. They have a comprehensive list of all the billable diagnosis codes for a specific procedure code, and it's color-coded by diagnosis. Our fee sheets are also color-coded. It's a unique system."

For patients covered by a commercial insurance plan, Ms. Abel has devised a Lucentis authorization sheet. "If a patient's insurance carrier requires precertification, our billers insert the authorization sheet into the chart," she explains. "When the physician determines the patient will receive Lucentis, that chart is brought back to the billing department, and they call the insurance company for the precertification. Our staff won't dispense the drug until they are 100% confident that authorization has been received."

According to Dr. Slakter, the practice uses more than 1% of all the Lucentis in the United States, and its collection rate is close to 100%.

At Retina Consultants of Houston, the staff member assigned to help facilitate reimbursement works with patients who have commercial insurance or those who may be receiving Lucentis for a nonapproved indication to obtain pre-approval for treatment and determine any out-of-pocket expenses. "This isn't a foreign concept to physicians," Dr. Brown says. "We're accustomed to doing this for surgeries."

Frequently, the specified staff member or the individual patient will use resources available through the Genentech Access to Care Foundation (GenentechAccessSolutions.com) to help calculate the patient's out-of-pocket costs and to determine if the patient is eligible for financial assistance or free drug.

"For diabetes patients, and until recently for vein occlusions, we found it was more efficient to contact Access Solutions upfront to avoid any surprises for the patient," Dr. Brown says. "Although patients can call Access Solutions directly and speak to a live person, we found our elderly patients appreciate our assistance. A 92-year-old in assisted living who is concerned about her financial stability may worry that the stranger on the phone who is asking questions about her income may be trying to rob her of her pension."

Adding a full-time employee to handle insurance and reimbursement issues is an extra expense for the practice, Dr. Brown admits, but he believes it's a worthwhile investment. "The upfront work helps us ensure that our patients have access to the available resources, either through their insurance or the drug manufacturer," he says. "If we don't do that work upfront, we very likely could give an expensive therapy to a patient who can't afford to pay for it."

CODING THE EXAMINATION FOR MEDICARE

Although receiving reimbursement from Medicare for anti-VEGF therapy for approved indications is generally straightforward, Dr. Kaiser notes a Medicare carrier may need to be educated about the need for a full examination, including OCT. "In Ohio, we had an issue with reimbursement for the visits when patients were receiving Lucentis injections," he says.

"Basically, the agency accepted that patients were being treated but didn't reimburse for the examination. We've since explained — and they now understand — that we must perform a full examination in order to make an appropriate treatment decision. This required a concerted effort by our billers and even letters from physicians to the carrier director, explaining what we do and why we do it."

Jeffrey S. Heier, MD, Ophthalmic Consultants of Boston, agrees Medicare may take issue with the examination and also OCT scans. He believes patients need a full examination at least every quarter and OCT scans at most visits, if not every visit. "My advice is to do what is reasonable, based on sound medical judgment and in the best interest of your patients. Medicare may argue, and that is their prerogative, but at least you've based your actions on sound medicine." RP