Immediate Threats to Your Infusion Business
The most significant threat to your infusion business since the Most Favored Nation model promises to close infusion center doors across the country unless you join the fight to stop it.
Your practice may stand to lose a minimum of $150,000 per year in revenue for every 100 patients. Your patients need your engagement and support today to keep your infusion practice in business tomorrow!
Government payors are jeopardizing patient access to critical drugs:
The Medicare Administrative Contractors (MACs) have recharacterized complex biologics as “simple, therapeutic” injections, like B-12 shots, by issuing Local Coverage Article (LCAs) that inaccurately present those changes as mere “re-education” relating to coding corrections. The MACs are circumventing the statutory requirements for publishing Local Coverage Determinations (LCDs) and substantive legal standards governing payment because they want to avoid input from infusion practices and other stakeholders. This is wrong; all stakeholders should have a voice, and the MACs should listen to those voices before making misguided decisions that jeopardize patient access. Unfortunately, commercial payors have taken notice of the conduct by the MACs and are beginning to use “fact sheets” to drive similar changes for their plans.
What have advocacy groups been doing to stop this?
Last Summer, several groups joined the National Infusion Center Association (NICA), the trade association formed to fight for physician office infusion suites and ambulatory infusion centers, to send a letter to CGS, NGS, Noridian, and Palmetto. Similarly, several organizations, like the American Academy of Neurology, the American College of Rheumatology, and the Coalition of State Rheumatology Organizations, have also explored all advocacy avenues to find resolution. Our exhaustive efforts to work directly with the individual MACs and CMS to persuade them to withdraw the LCAs have not been successful.
NICA’s position is on all fours with other leading organizations. You can read the American College of Rheumatology’s (ACR) position here and an article from the current President of the Coalition of State Rheumatology Organizations (CSRO) below.
The Problem Is Escalating
On April 21, 2022, First Coast Service Options (FSCO) released an LCA to drive the same policy change, effective June 6, 2022. Now all MACs have stopped reimbursing complex biologics at complex codes, and commercial insurers and employer plans will quickly follow. As of August 1, we have received reports that major commercial payors, including UHC, have begun to down-code, citing this “new CMS policy”.
With the significant increase in staff wages and overhead costs, these changes exacerbate the underlying cost-reimbursement disparity to the point of potentially disrupting infusion center economics and forcing a massive displacement of patients to more expensive care settings for their infusions/injections or to disease flare management in the Emergency Department. Such a disruption would negate the value and cost-savings potential your infusion centers represent.
The result will be catastrophic for access to the drugs people need to optimize health outcomes, maximize their quality of life, and minimize the physical, emotional, and economic burdens of disease. The implications to Medicare will also be great as Part B patients across the country are disrupted and forced to consume exponentially more—and higher cost—health care.
What will NICA do about this?
NICA is gearing up to fight the misuse of LCAs through education, advocacy, and all available legal means. But, as your trade association, we are only as strong as the support behind us. We cannot fight this fight without engagement and support from every infusion center across the country.
What do we need from you?
Your practices stand to lose patients and hundreds of thousands, if not millions of dollars, due to the misuse of LCAs. We need strong support from each one of you to win this fight and position the infusion delivery channel to play a critical role in the future of health care. We estimate that success will require $1.5 million in total funding and are asking each infusion center to donate $5,000 to the cause (which is a small fraction of the likely economic impact on your center if the federal policy continues unchecked). Your center may donate through our GoFundMe (https://gofund.me/284df137) or directly via check to avoid processing fees (email [email protected] for instructions on direct contributions). All contributions made through GoFundMe will be documented anonymously in GoFundMe.
NICA has pledged $100,000 on top of the costs we’ve taken on thus far. AARA – powered by Bendcare, contributed $100,000, and additional commitments from others have gotten us started. Unfortunately, that is not enough. We must raise $1.5 million to succeed in preserving the non-hospital infusion/injection delivery channel.
In addition to financial support, we need you to email the following to [email protected]:
- Any examples of claim denials for drugs included in the applicable LCA when billed at high-level codes
- An estimate of your practices total expense per infusion service hour.
- A statement that the drugs in the applicable LCA for which you provided claim denials warrant the complex codes because they:
- Require clinician supervision
- Require specialized skills and training to handle, prepare, administer, as well as monitoring for and addressing reactions;
- Have greater incidence of adverse events well beyond that of a simple therapeutic injection/infusion;
- May require adjustments in drip rate based on how the patient is tolerating the medication
- An estimate of the financial harms your practice(s) will face (or has faced if your MAC down-coded already), and the implications to your patients if they must instead get treated in the hospital.
We can win this, but it will take vigorous engagement and a strong financial investment to position community-based infusion as the future of health care.
The content in the above resources is meant to be used as general guidance and should not be interpreted as legal advice. NICA is not responsible for damages resulting from the use of the materials.