Patient financial/co-pay assistance is usually a component of providing infusion services and practices need to make sure it’s carefully managed to prevent financial hardship to patients.
In-office infusion therapy has become more prevalent over the past decade, as the service provides many benefits to both physicians and patients. Physicians increase proximity to patients, closely monitoring disease progression, adherence, and treatment efficacy.
Financially, a new revenue stream may be created for the practice. Patients also reap rewards, as they receive vital care in a convenient location from the care team they know and trust.
Although this sounds like a win-win situation, in-office infusion is a complex process that adds a high level of risk to the operation. There are many factors to consider before investing in this service, as well as best practices to employ if the decision is made to proceed.
It is critical to understand all that goes along with opening a center, so taking a closer look at these issues is worthwhile.
Careful consideration is needed
The decision to invest in an infusion facility should not be rushed. Carefully vetting each aspect can take several months, and once a practice decides to go forward, a few more months are needed to set up the operation correctly.
Depending on the size of the facility, it may take from 4 months to a year to vet everything and build out a center. The following are key activities for practices considering whether to open a center:
Conduct an ROI/risk analysis
Take time to do an appropriate financial viability review. Does the practice have enough patients with the right payer mix to be viable? I recommend a ratio of 60/40 to 70/30 in commercial versus government payers.
Does the practice have a good GPO and distribution partner to acquire drugs at competitive market pricing? Does the practice have the appropriate number of clinical and billing support staff with relevant experience associated with infusions?
Ensure payer credentialing and contracting
Is the practice credentialed with all relevant payers and contracted with them at competitive fee schedules to administer infusion drugs?
Determine the infusion space
Does the practice have the appropriate space for an infusion center, which must be in the same suite as the practice? How many chairs are needed to support the anticipated patient volume? Enough space is needed so the treatment area is not cramped and uncomfortable.
Is there space for drug storage? Consider all elements that may be needed, such as a temperature-controlled and monitored refrigerator, locking cabinets, nurse workstations, and other items that may be required by state regulations, such as a sink.
Examine staffing capabilities
Does the practice have experienced billing staff for acquiring authorizations and billing complex infusion codes? This requires an entirely different skill set than office visit billing.
Does the practice have the appropriate clinical nursing staff with relevant training and infusion experience? A rendering provider must always be on site, so consider how to make certain a provider will be at the infusing office whenever infusing occurs.
Best practices for long-term viability
With the many challenges in running an in-office infusion center, ensuring success can be difficult. Close attention must be paid to all aspects of the operation at all times. Implementing a few best practices, such as those below, can make that task a bit easier:
Utilize properly trained and experienced clinical staff
The facility must have nurses with experience in infusion therapies, and they should be trained in all of the specialty drug treatment protocols, such as how the drugs are infused, how often to administer, side effects, and other critical elements that impact patients. For safety considerations, I believe no more than 4 patients should receive an infusion per 1 nurse on duty.
Ensure appropriate revenue cycle support
Infusion claims are not like typical office visit claims, and they require special knowledge and skills. Utilize either a reputable billing company with experience in complex buy and bill infusion procedures or an in-house billing team with relevant experience.
Most, if not all, infusions require prior authorizations from payers before the patient receives treatment. Claim denial and audit expertise is critical because denials are common.
Staff must be adept at dealing with medical necessity, medical records, and completing tasks that go along with appealing denials. Patient financial/co-pay assistance is usually a component of providing infusion services and practices need to make sure it’s carefully managed to prevent financial hardship to patients.
Employ the proper technology
Technology can empower best practices and processes, which helps to drive success. Using the right infusion scheduling software can optimize chair time to reduce costs.
Inventory management software is also critical to effectively manage the costly specialty drugs required and to minimize cash flow disruptions. Top quality billing software is also vital to ensure services are billed appropriately and timely.
Provide robust patient support
Patients have more choices than ever before in where they are treated, therefore, providing a great patient experience is imperative. Practices should employ many different components to support the patient.
Patient education around treatment protocols is critical, as well as comprehensive financial counseling so patients understand treatment costs and out-of-pocket expenses. Helping them access financial assistance resources is also critical because finding and enrolling in these programs is daunting.
Enhancing an existing program
Practices with an existing infusion center should do a quick check to ensure they are maximizing their potential. Closely examine commercial payer contracting, which has a huge impact on profitability.
If reimbursement rates are not at 100% of Medicare for commercial fee schedules, try to renegotiate the contract for better rates. Community practices have a payer value proposition, as infusions in the community are approximately 50% cheaper for payers than in the hospital.1
Next, closely examine revenue cycle management. Money is being left on the table if the collection rate is below 98%, creating risk within the practice. Partner with a reputable billing company, infusion management company, or invest in continuing education for your billing team.
A few other areas are worth a closer look. Check the aesthetics of the infusion center. Patients want to come to a clean, modern space because they spend a significant amount of time there.
Make their experience as enjoyable and comfortable as possible, as this builds loyalty and generates referrals. Finally, practices can explore growth opportunities with outside infusion patient referrals.
Infusion centers are not for everyone
Deciding to add an infusion center is a complex decision. A lot of critical elements must fall in line to make the option viable.
Practices must have the right patient volume and mix of commercial versus government payers in their patient population. They must also understand and mitigate the financial risks of infusion because they are substantial.
Infusion drugs will be the single highest cost item in the practice and, if not managed effectively, they can quickly create tremendous financial risk. In the end, infusion centers may not be a good choice for all practices but for those who have carefully done their homework and chosen to offer the service, best practices can play a vital role in driving ongoing success.
1. Dec. 2019; “Commercial specialty medication research: 2019 benchmark projections”; Page 14; Milliman; https://www.milliman.com/-/media/milliman/pdfs/articles/commercial_specialty_medication_-research_2019_benchmark_projections.ashx
About the Author
Luke Rubie is vice president of Provider Engagement, Intrafusion by McKesson.