Top 4 Challenges in Infusion Billing and Their Solutions

Infusion billing is a process to administer fluids inside the patient’s veins. It incorporates charging the medication, method of administration of the fluid, and the duration which need precise start and stop time. There are five key aspects of infusion billing including time-based coding, administration methods, drug wastage, documentation, and complex coding. There are mostly three types of infusion which include initial, subsequent, and concurrent infusion.

The initial infusion is the primary drug infused inside the patient’s vein which lasts longer than 15 minutes. The subsequent infusion is administering the same drug following initial infusion. Finally, the concurrent infusion is infusing two or more drugs simultaneously through the same intravenous line. However, billing for this process is a very complex affair as you need to use the right codes and modifiers to streamline the claim submission process. Hence, as the healthcare staff stay busy with administrative hassles, this is why it can be a feasible option to outsource a reputed infusion billing company in that matter.

Understanding the Infusion Therapy Market

The infusion therapy market in the US has seen substantial growth in the last couple of years. Due to the advancements in biologics, chronic disease and outpatient care are highly evolving. One of the major reasons for this growth is due to the increasing aging population having co-morbid conditions. Moreover, there are increased approvals for specialty drugs,as the shift from inpatient to the outpatient infusion suites and value-based care need cost-efficient treatment settings. It has been observed that the infusion therapies are becoming more complex with time which is creating several problems for the clinics to get reimbursements.

Challenges in Infusion Billing

Infusion is considered as one of the complicated areas in healthcare because you are dealing with all time-based procedures, payer rules, high-cost drugs, and prior authorization together. Now, let’s delve into those challenges:

1. Complex Coding Process

The infusion therapies incorporate expensive medicines which need to be billed using the right HCPCS or J codes. The major challenges includes the change in drug codes, and different payers need different billing models. The in-house teams need to use the right codes, drug description, and dosage units to make sure no issue occurs. Even a tiny mismatch amongst the billed code and administered drug will lead to claim denials. As the infusion drugs are highly costly, the coding process also becomes highly complex.

2. Prior Authorization Needs

The major infusion therapies including specialty drugs and biologics need prior authorization from the payers. However, if you are planning to obtain authorization, it involves submitting the right documentation along with proving the patient’s medical necessity. This process can take a long time, sometimes weeks also. However, if the prior authorization is not properly obtained or expired before the treatment, the payers may reject payment. Always remember that managing the authorization process requires constant communication amongst billing teams, physicians and insurers.

3. Several Documentation Needs

Infusion billing needs detailed clinical documentation to make sure clinics get the payment for the rendered services. These documentation entails:

• Dosage administered and drug names

• Infusion start and stop times

• Administration route

• Understanding the patient’s medical necessity

• Details of patient monitoring

You need to know that incomplete documentation can lead to claim denials, and that is why accurate documentation is essential to make sure no issue occurs.

4. Changes in Payer Policies

The payers have different policies for all the infusion therapies. Some payers need drugs to be billed under the pharmacy benefit and others use the medical benefit process. The covered drugs, coding needs and reimbursement rules constantly change amongst payers, and it makes the in-house teams to stay updated with the billing changes.

How the Outsourced Infusion Billing Company Helps?

These third-party experts take several steps, starting with streamlining your prior authorization procedure to using the right technology. These experts stay updated with all the latest CPT, ICD, and HCPCS codes to make sure no claim denial occurs. Moreover, they also know all the complex nuances of the HIPAA law to protect patient data. Hence, with their help, you can stay ahead of all the latest coding changes.

These outsourced services know how to tackle the prior authorization procedures. They streamline this process using several steps such as first identifying the patient’s insurance eligibility, collecting the right documents, and finally submitting prior authorization requests to make sure no issue occurs. So, it basically incorporates initiation, submission, and follow-up to make sure the clinics get the right reimbursement.

It has been observed that the in-house teams come at a high cost because you need to train them and buy expensive office space for them. Hence, it increases a lot of costs for clinics. On the other hand, third-party billing experts get constantly trained and don’t need any separate office space, which significantly reduces their cost. Hence, this is also one of the major reasons to hire in-house staff.

Finally, these experts know how to use the right technology to fasten the claim submission procedure. They know how to work with the clinic’s Electronic Health Record (EHR) system to store patient data and Electronic Prior Authorization (ePA) procedure to submit claims electronically.

Key Factors to Look Before Hiring a Billing Expert

The future of infusion billing looks completely promising because of the advancements in AI in this space. Hence, there are several factors you need to check before hiring any billing expert such as checking if they can reduce your operational costs by 80% and work with 10% buffer resources to make sure no issue occurs. Moreover, check if these third-party experts provide dedicated account managers and no binding contracts or restrictive clauses.

There are very few companies who provide insurance coverage of $1 million or more in case any issue occurs from their side, so try to hire them. These experts not only help with infusion billing, but also, they provide assistance with DME, gastroenterology, cardiology, and many more specialties. So, if you want to streamline your billing process, it can be a feasible option to outsource infusion billing company in that matter.