OPI Is Key to Avoid Losing RA Reimbursement

Infectious disease physicians can lose valuable income if they unnecessarily refer rheumatoid arthritis (RA) patients to rheumatologists or if they fail to adequately market their capabilities to rheumatology specialists, coding and reimbursement experts say.

The key in both instances, says Dianna Hofbeck, RN, CCM, president of North Shore Medical Inc. in Abescon, N.J., is the ability of the infectious disease (ID) physician to perform outpatient infusion therapy (OPI). For example, Hofbeck says, if an ID physician does not provide patients with office-based IV therapy and, therefore, must refer RA patients to rheumatologists for treatment, its more than likely that the rheumatologists office will bill and collect for some form of compensation for IV services. But, whats even worse, from the ID physicians point of view, the patient may never return to that office for further management of the arthritic condition. And theres also the ever present threat of an overlying infection that must be treated. Similarly, Hofbeck points out, the ID physician may lose revenue if RA patients must be referred to infusion companies. In those instances, says Hofbeck, pharmacists or business owners often receive the reimbursement.

On the other hand, Hofbeck explains, say the ID physician obtains a detailed patient history, receives supporting documentation from other treating physicians, performs all appropriate laboratory testing, identifies and prescribes state-of-the-art treatments and makes a clear diagnosis of rheumatoid arthritis. If the ID physician has the ability to administer OPI in the office and establish a partnership relationship with the patient, why not bill and collect for these services? The doctor/patient relationship also will help to ensure that the patient will return for future care, says Hofbeck.

In many instances, rheumatologists treating RA patients may not be aware of the OPI capabilities of the infectious disease physicians in their communities. An ID physician needs to market his OPI capabilities to the rheumatologists managing these patients, so that, if they prescribe Remicade (the current drug of choice), they may refer their patients to the ID physicians OPI program for their infusions, says Barbara Ross Nolet, RN, MA, president of Northwest Management Associates in Gig Harbor, Wash.

Nolet points out that, in those situations, the rheumatologists manage their patients treatment and response, and the ID physicians simply oversee the infusion procedures. The ID physician then would be responsible for the venous access device selection, insertion and management, as well as the actual drug administration procedure and monitoring.

So, whos responsible for educating the patient? According to Nolet, patient education regarding the drug and its expected response might remain the responsibility of the referring rheumatologist; however, patient education regarding the venous access device, the overall schedule and plan and the drug administration procedure would be provided [...]

- Published on 2000-04-01