In response to changes in healthcare delivery, coverage policies and payment, physicians
frequently must obtain prior authorization for services to ensure coverage and appropriate payment by the patient’s
Securing contractual reimbursement for plasma-derived therapies in accordance
with applicable laws, rules and regulations is absolutely necessary, in particular for the use of IVIG. IVIG is addressed as a separate billing and coding issue for the following reasons:
There are a number
of FDA approved IVIG products, all by different manufacturers with varying Indications For Use (IFUs).
Many payers have specific
medical policies governing coverage for the use of IVIG.
Data indicates that
a majority of the uses for IVIG occur off-label, based on the medical judgment of the physician after evaluating the patient’s
clinical status and treatment alternatives.
Most reimbursement criteria require
the least-expensive treatment alternative, the physician must be able to document reasons that support medical necessity in
order for the payer to justify use, and approve use and payment for the more expensive product.
In addition to the skills and abilities of the physicians and the technical ability
of the manufacturers to produce a safe and effective product, the success of any patient’s treatment plan may be impacted
by the willingness of the health insurer to pay for treatment.
Much of the work in the reimbursement process is routine: use an appropriate
diagnosis code with the correct procedure code, CPT code, supply code or NDC and the claims will be processed and paid. Payments are routinely made according to the payer’s medical policy on coverage,
the patient’s benefit plan, various payment methods and any contractual agreements with the providers.
With any treatment plan, the strategy for securing optimal reimbursement must include
certain key elements. With these key elements in place, the reimbursement process
should proceed without any delays.