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Loosing money on medications??

  1. Default Loosing money on medications??
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    Is the anything you can do with insurances not reimbursing enough for medications?? Such as mitomycin, gemcitabine and valrubicin, Lupron?? We are paying much more in some cases than the insurance reimburses. Especially Medicare. Can you appeal to get the amount you paid for the medication reimbursed?? It doesn't seem fair that we loose money for trying to give cancer patients the best treatment. Is there something that I'm missing, something else we can do??

  2. #2
    I don't believe there is anything you can do to get additional payment just because your specific practice's expenses are high. We used to perform chemotherapy in the office back when we were a private practice. Around the time Medicare drastically changed their medication/administration policy (2006 if I recall correctly), we changed how we obtained medications. Medicare (and most private payors) will reimburse J codes based on AWP (average wholesale price). So, if a huge healthcare system is buying these meds by the barrel and a great price, and you are buying them by the vial at a much higher cost, you will definitely lose money.
    We created a simple grid spreadsheet for our nurses. Insurance company in the columns. Medication on the rows. Every square had a red, green or yellow coding. Green meant we would supply (buy & bill) the med. Yellow meant we could, it was discretionary. Red meant we would still administer the med, but would not supply it. Which usually meant specialty pharmacy. So if a patient was getting 2 meds - 1 green, 1 yellow - we would buy & bill both. If it was 1 red, 1 yellow - we would obtain both from an outside vendor.
    We no longer perform chemotherapy in our office, but do sometimes administer Lupron Depot, or other J codes (like an IUD). However, since we are now part of a large healthcare system with their negotiating power behind us, the cost for us to obtain those medications or devices is far less.
    If you are still an independent practice in the current healthcare billing and reimbursement environment, it is virtually impossible to not lose money on J codes. If you are part of an IPA, they may be able to assist in negotiating better costs for the medications.
    Good luck!
    Christine M. Speroni, CPC
    Admin Manager
    NHPP Gynecologic Oncology

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