This week I received a call from an infusion company that wanted help with recovering a large accounts receivable balance. This amount was based on one particular drug therapy for one specific payer. The insurance company had originally paid some of the initial claims and then advised the provider that the claims were paid in error. The provider would have to payback the monies or the payer would offset payments on future adjudicated claims. Furthermore, the payer informed the provider that the patient could not be held liable for the charges. Say, what?
The issue at hand was the fact that the manufacturer’s indications for the drug were that it must be administered in a clinical environment and under the direct supervision of a physician and that it was not approved for administration at home. The provider contended that the physician ordered the drug to be administered at home and that they were simply following the doctor’s orders. The provider did not obtain prior-authorization as it was not required for the patient’s plan. During this time (eight weeks plus) the patient continued to receive therapy at home. This was probably not a good idea.
The therapy was expensive. Clearly the provider was counting on a big profit and did not want to question the physician’s orders. Probably based on the high dollar amount of the case, the insurance company’s medical review department researched the manufacturer’s recommendations and found their way out of paying the claims. The sad part is that all of this could have been avoided if the pharmacist had questioned the order or if possibly the provider had obtained specific authorization which allowed for administration at home.
The appeals have stopped. The provider is licking its wounds and the patient is much better. A tough lesson learned…providers should consult the manufacturer’s indicated use and instructions for administration of any drug therapy with which they are not familiar. Infusion providers must choose wisely, know the hidden rules and play the game to win.