The high cost of retina drugs means practices need to be reimbursed correctly and efficiently to maintain a thriving operation. Paying attention to three items can affect your reimbursement.

Contract Terms

Payer contracts contain the terms of reimbursement. These terms can include fee schedules that list drug Healthcare Common Procedure Coding System (HCPCS) codes, references to Center for Medicare & Medicaid Services’ average sale price (ASP) and formulas for calculating reimbursement when claims are submitted properly.

The world of retina drugs is ever evolving. New drugs that have not yet been assigned an HCPCS code are considered as “not otherwise classified” (NOC). When contracts define that HCPCS NOC drug codes are paid at a percentage of the billed fee, practices need to ensure their submitted fees are adequately set so the contracted reimbursement percentage will cover the cost of the drugs.

Prior Authorization Requirements

Start with asking, who is the payer? Prior authorization (PA) requirements vary per payer and per drug. For intravitreal injections, payer policies may require a lower cost drug to have a documented failed response before approving a physician preferred drug. This type of policy is called step therapy, and it can affect the prior authorization process.

Locate unique policies for the injection procedure and the drug. Ensure documentation meets medical necessity as defined by the payer. Check for prior authorization requirements before performing the service. Most payers will not grant retroactive authorizations outside of emergency care. Reverify eligibility and benefits for every patient on every visit since plans can change.

Remember that having prior authorization does not guarantee reimbursement. Payment is based on the patient's eligibility. However, not having prior authorization when it’s required will guarantee you will not get reimbursed. Learn more about prior authorization.

Improper Billing

A comprehensive understanding of how to code for injectable drugs is essential for correct payment without unnecessary delay. Mistakes made in selecting the drug code, factoring the units to bill, linking the correct diagnosis, and/or addressing drug wastage can be expensive. Time spent appealing denials caused by coding and billing errors reduces productivity and profitability. All retina support staff should recognize the cost of retina drugs and be adequately trained to ensure clean claims are submitted to every payer every visit.

You can find Academy resources for retina coding and billing at Practice Management for Retina.

AAOE® members can access resources on how to Utilize Dashboards to Monitor Drug Productivity and Profitability that were previously shared by AAOE Board member Jessica Schroeder, MPH, CPC, OCSR.