MANAGED CARE July 2010. ©MediMedia USA
It’s not often that commercial insurers get a pat on the back, but a recent Government Accounting Office study that compared home infusion coverage for Medicare beneficiaries and commercial insurers comes pretty close. The GAO study examined the
extent of Medicare fee-for-service coverage for this therapy. It found that coverage depends on whether the beneficiary is homebound and on other factors related to the beneficiary’s condition and needs.
In particular, there was a distinct difference in how commercial insurers and Medicare cover this therapy.
Commercial insurers provided comprehensive coverage of home infusion therapy under network-based MA plans, which may provide benefits beyond those required under fee-for-service (FFS) Medicare.
Nationwide, nearly 1 of 5 MA beneficiaries has comprehensive coverage through an MA plan that offers home infusion therapy as a supplemental benefit.
Some homebound Medicare FFS beneficiaries receive comprehensive coverage of home infusion therapy, which includes drugs, equipment and supplies, and skilled nursing when needed.
On the other hand, for beneficiaries who are not homebound, Medicare FFS is limited to the necessary drugs, equipment, and supplies, excluding nursing services.
For nonhomebound beneficiaries, Medicare FFS is further limited: Infusion drugs may be covered for those enrolled in a prescription drug plan, but neither equipment and supplies, nor nursing services is covered. This group of people would need to obtain infusion therapy in a hospital, nursing home, or physician’s office to have all therapy components covered.
When it comes to utilization, the commercial insurers in the study report using standard industry practices to manage utilization and to ensure quality of care.
Specifically, most commercial insurers require that infusion providers submit patient information in advance to support a request for coverage and receive payment authorization.
Insurers also report that they review samples of claims after payment to determine if they were billed and paid appropriately. None stated that they have had significant problems with improper payments or quality for home infusion therapy services.
In addition, commercial insurers report taking various steps to ensure the quality of services delivered in the home, including developing a limited provider network of infusion pharmacies and home health agencies, requiring provider accreditation, coordinating care by providers, and monitoring patient complaints.