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IVIG Reimbursement
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UCLA Physician Services

Intravenous Immunoglobulin

 

 

     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 health insurance. 

 

     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.