Approaching Medicare's New Infusion Benefit
CMS has deemed a new infusion benefit that can be an opportunity for DME pharmacies. But it's important to understand how the benefit works and how accreditation plays a role.
Effective Jan. 1 of this year, Medicare began covering
the provisioning of infusion therapy-associated
services and devices in the home. This has created
new opportunities for DME pharmacies that have long
been providing care and DME items to homecare patients in
their communities.
So what makes home infusion so unique? Many infusion
therapies are provided by a specialist provider’s office or in an
ambulatory infusion center, but for many homecare patients,
ambulatory infusion is difficult or not desirable, so home infusion
therapy is available.
However, up until this year, Medicare did not cover home infusion
therapy services. The 21st Century Cures Act changed all
that. Signed into law in December 2016 by then Pres. Obama,
the Act said that effective Jan. 1, 2021, Medicare would cover
intravenous or subcutaneous administration of drugs or biologicals
through a pump that is an item of DME in the home setting.
The law added that the new home infusion therapy should include
professional services (including nursing services); training
and education (not otherwise included in the payment for the
DME); and remote monitoring, and other monitoring services
for the home infusion therapy.
So how do DME pharmacies interested in this new benefit
approach this new benefit?
It begins with understanding the benefit and how to qualify
for providing to Medicare beneficiaries, explains Sandy Canally,
RN, founder and CEO of accrediting organization The Compliance
Team (thecomplianceteam.org) says that the new benefit
represents a solid opportunity for enterprising DME pharmacies
looking to expand their revenues, and the pathway toward
tapping into it is not that difficult to negotiate.
The first thing to understand: like being a pharmacy or providing
DMEPOS for Medicare, it requires accreditation.
“Providers that want to bill for home infusion and get paid
must be accredited by one of the recognized accrediting
organizations,” Canally says, adding that her organization,
The Compliance Team, is deemed by Medicare for accrediting
home infusion. “So, anyone who is interested in getting into
that sector of care, you need to make sure that you’ve been
dealing with an AO that they are, in fact, recognized by CMS for
home infusion.”
It’s important to note that home infusion accreditation has
been around a long time (people have obliviously needed
home infusion for as long as the care has been around), and
there are many AOs such as The Compliance Team, that go way
back in accrediting home infusion.
“What has changed is that is a benefit has come into play,”
Canally says.
Also, when it comes to this new benefit and infusion care for
Medicare beneficiaries, there are three roles that are played in
provisioning home infusion that DME pharmacies need to keep
in mind:
- The durable medical equipment element, which is the pump.
- The drug that needs to be infused, which means a pharmacy
needs to be in the mix.
- The administration of the infusion therapy to the patient,
which is typically carried out by nurses.
“Now, any one of those three entities could be the billing
provider,” Canally explains. “In which case, the other two might
be a subcontractor to that providers. Or, a DME provider or a
pharmacy could be the subcontractor to a nursing agency.”
Or, if a DME pharmacy is involved, “They might do it all,”
Canally says. “They might have their own nurses, which most of
the pharmacies that we’ve accredited for infusion — going back
quite a few years — have actually had all of those components.”
(At this point, a light bulb most likely just lit up over your
head.)
So for any DME pharmacy that is considering Medicare’s
new infusion benefit as a way to drive new revenue and care services,
what’s the best way to approach the opportunity. Canally
says a solid way to get started is to look for local partnerships. If
a DME pharmacy isn’t ready to offer pumps, it could partner up
with a local DME provider. Or if it offers the pumps but doesn’t
have nurses on staff, then it could partner with a nursing agency
that specializes in infusion.
For the accreditation component of the service, Canally
says her business looks at all aspects of the business seeking
accreditation.
“If you’re interested in home infusion and getting accredited,
the one thing that you need to have prior to a visit from
the accrediting organization are patients that are actually being
served in the home,” she says. “Ambulatory infusion, which a lot
of providers do and that we’ve been accrediting for years, does
not come into play here. This benefit is only about patients getting
infusion therapy in the home.”
This article originally appeared in the DME Pharmacy December 2021 issue of HME Business.