When it doesn’t pay to treat patients

September 18, 2018
Melissa Young, MD

Practices sometimes can’t afford to administer treatment to patients given the risk of denied reimbursement claims.

Editor’s Note: Physicians Practice’s blog features contributions from members of the medical community. These blogs are an opportunity for professionals to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general or healthcare reform. The opinions are that of the writers and do not necessarily reflect the opinions of Physicians Practice or UBM.

As an endocrinologist, there are some medications that can or must be administered in the office. Sometimes, we need to administer a drug prior to performing a test. Other times, it is for therapy.

Some drugs the patient obtains through their pharmacy, and we administer it in the office, such as testosterone or intravenous ibandronate for osteoporosis. In those cases, it is fairly straightforward from a practice standpoint. We send the prescription to the patient’s pharmacy, the patient picks it up after jumping through all the prior authorization hoops, the patient brings in the medication, and we administer it. Other times, it is more complicated.

Expensive drugs like denosumab (Xgeva, Prolia), also for osteoporosis, are sometimes covered under the patient’s prescription plan but are shipped to the practice from a specialty pharmacy. Other times, particularly for patients with Medicare, prescriptions are covered under the patient’s medical benefit, but the practice must “buy and bill.” That is to say, the practice must purchase the drug, administer it, submit the bill, and wait for reimbursement. Before we do that, we have to check and verify that it is a covered benefit. We get reimbursed most of the time. But verification that a drug is a covered benefit doesn’t always mean that it will be covered for a particular patient.

We have unfortunately learned this the hard way. Once the claim is submitted, the payer can still deny payment. The payer can claim the drug was not medically necessary. The payer can say the patient should have tried other medications first. The payer can say the documentation didn’t cross the T’s and dot the I’s.

We don’t make any money by administering the drugs in the office, so all it takes is one denied claim for us to lose hundreds of dollars. It happened to us often enough that we have decided to stop administering those medications altogether.

Fortunately, our local hospital has an infusion center where we can send out patients for injectable medications. We still have to be the ones to verify coverage, and we need to send all the required documents to the hospital. We still do all the legwork, but at least we don’t have the financial risk for denied reimbursements that we once did.

Some of our patients are disappointed they can’t get their treatments when they come in for their visits with us. It’s an extra trip for them. We’re frustrated we have to send them out for treatment. But unless they can pay for the drug if it gets denied-and of course they can’t-we can’t afford to take the chance anymore.

Melissa Young, MD, FACE, FACP, is sole owner and one of two physicians at Mid Atlantic Diabetes and Endocrinology Associates, LLC. As such, she is both actively involved in patient care and practice management while also raising two kids and a dog in suburban New Jersey.