Spravato vs. Antidepressants: Which is Better?
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Understanding the Differences Between Buy-and-Bill and Assignment of Benefits for Spravato® (Esketamine)
Spravato® (esketamine) nasal spray is a groundbreaking treatment for treatment-resistant depression (TRD) and major depressive disorder (MDD) with acute suicidal ideation or behavior. As its use grows, healthcare providers and patients must navigate different payment models to access the medication. Two common billing methods are buy-and-bill and assignment of benefits (AOB). Let’s explore how these models differ and what they mean for providers and patients.
What Is Buy-and-Bill?
The buy-and-bill model involves the healthcare provider purchasing Spravato® directly from the manufacturer or distributor and then billing the patient’s insurance company for both the drug and the administration.
How It Works:
- Procurement: The healthcare provider buys Spravato® in advance and keeps it in inventory.
- Administration: The provider administers the drug in-office, typically as part of a scheduled treatment plan.
- Billing: The provider submits a claim to the patient’s insurance for reimbursement, which includes the cost of the medication and associated services like administration and monitoring.
Advantages of Buy-and-Bill:
- Control: The provider manages the drug supply, ensuring timely access for patients.
- Convenience: Patients do not need to coordinate payment or delivery of the medication themselves.
- Revenue: Providers may benefit financially if reimbursement rates exceed procurement costs.
Challenges of Buy-and-Bill:
- Financial Risk: Providers must front the cost of the medication, which can be expensive, and there’s a risk of denied or delayed insurance reimbursement.
- Administrative Burden: Requires careful inventory management and complex billing processes.
What Is Assignment of Benefits (AOB)?
In the AOB model, the insurance company pays the cost of Spravato® directly to the specialty pharmacy, bypassing the provider.
How It Works:
- Prescription: The provider prescribes Spravato® to the patient.
- Pharmacy Coordination: The specialty pharmacy handles the insurance claim and ships the medication to the provider’s office.
- Administration: The provider administers Spravato® to the patient and bills separately for administration and monitoring services.
Advantages of AOB:
- No Upfront Costs: Providers don’t need to purchase and stock the medication.
- Simplified Reimbursement: The pharmacy handles insurance claims for the drug itself, reducing the provider’s financial risk.
- Patient Access: AOB can streamline access for patients, especially if their insurance mandates the use of specialty pharmacies.
Challenges of AOB:
- Coordination Delays: Delays in pharmacy processing or insurance approvals can disrupt treatment schedules.
- Limited Control: Providers rely on third parties for timely delivery of the medication.
- Split Billing: Separate claims for drug costs and administration fees can complicate the process.
Key Differences Between Buy-and-Bill and AOB
Which Model Is Right for Your Practice?
The decision between buy-and-bill and AOB depends on the provider’s resources, patient population, and operational preferences.
- Buy-and-Bill is ideal for larger practices with robust billing systems and the financial capacity to purchase Spravato® upfront.
- Assignment of Benefits (AOB) suits smaller practices or those looking to minimize financial risk and administrative complexity.
Considerations for Patients
Patients should be aware of how these billing methods impact their treatment:
- Out-of-Pocket Costs: Copayments or deductibles may vary based on the billing model and their insurance plan.
- Treatment Timeline: Delays in AOB coordination could affect the timing of their treatments.
- Insurance Requirements: Some insurers specify which billing model must be used.
Conclusion
Both buy-and-bill and Assignment of Benefits (AOB) are viable pathways to accessing Spravato®, each with distinct advantages and challenges. Providers should evaluate their operational capacity and patient needs to determine the best approach. By understanding these models, providers and patients can work together to ensure seamless and effective treatment for those living with treatment-resistant depression.
If you have questions about billing models for Spravato® or need support, consult with your insurance provider or a healthcare billing specialist.
