So, you have a contract…or do you?
This week I received a call from an infusion company that had recently expanded their therapies in order to capture a new segment of the infusion market in their area. Their issue is that now some insurance companies are refusing to pay them for their services. Why did this happen and how could it have been avoided?
The successful company has been in business for many years and simply wanted to expand. They did their research and identified the new therapies that they wanted to provide. They hired the clinical expertise that they needed. They understood and implemented the necessary billing codes in their computer system. They had conferences with cases managers and referring physicians in order to get their support and their referrals. And they already had existing contracts with many of the larger payers in their area…or so they thought. They were so sure that it would be a win, win, win. A couple of months after they took their first case they soon learned that their claims were being reduced to out-of-network benefits, as well as, being denied completely with no recourse for appeal.
Why? Many contracts these days limit the type of infusion therapies that an infusion pharmacy can provide. Years ago, as long as a provider had a payer contract for infusion therapies then the payer would designate them as an in-network provider for all types of infusion therapies. Not so anymore. Contracts are written to include coverage of specific therapies as indicated by the listed procedure codes. If the procedure is not listed in the details of the contract, then the therapy is most likely excluded. Don’t rely on the medical case managers working for the insurance companies to keep up with whether or not you are in-network or out-of-network for the specific therapy. They leave that up to you. If you tell them that you are, you better be telling them the truth…for your sake.
The moral of the story…know your contracts cover to cover. Used wisely, managed care contracts can help you reach the next level. Taken for granted, they can lead to disaster. Have a nice day!