Biologics buy and bill – buyer beware

Buy and bill for biologics was a hot topic this past weekend at the 2018 Annual Scientific Meeting in Seattle. During a presentation titled “Biologic Therapies in Your Practice,” James Sublett MD, FACAAI, discussed various aspects of choosing and billing for biologics in your allergy practice. Dr. Sublett reviewed the College’s new Severe Asthma Shared Decision-making Toolkit and discussed how it can help the allergist communicate the benefits of biologics to their patients. He also talked about using the College’s Prior Authorization Toolkit for navigating the pre-approval process required by many third-party payers for these new treatment options.

Related to billing for the administration of a biologic in the office, Medicare requires the use of CPT 96372 (Therapeutic, prophylactic, or diagnostic injection, specify substance, or drug; subcutaneous or intramuscular) while some carriers allow the use of CPT 96401 (Chemo administration, subcutaneous or intramuscular). Dr. Sublett recommended checking with your carrier to see if they will accept this code.

Although the idea of directly purchasing biologics for your patient may seem straightforward and potentially profitable, Dr. Sublett warned that it is important to set up and closely monitor the in-office process. Maintain very tight prior authorization and inventory control procedures – one way is by reducing the number of staff involved. Moving reimbursement each month requires extra-close monitoring of the Average Sales Price. You should track it individually by patient and by carrier. If you are starting to use a new biologic, he recommended beginning with one new patient and one carrier to determine if the reimbursement will cover the costs. Typical risks for using buy and bill include:

  • Change in carrier or loss of insurance by patient.
  • Change in co-pay.
  • Timing on deductible – if late in the year it’s generally low and – early in the year it’s generally high.
  • Loss or change in co-pay cards.
  • Change in rebates.
  • Change in reimbursement.

For more information, view the College’s free member webinar Biologic Basics: Pearls, Profits and Pitfalls presented by Advocacy Council vice-chair, James Tracy, DO, FACAAI.

Advocacy Issue: 
Billing, Coding & Payments