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Why Ensuring Payer Contracting for Buy-and-Bill Is Essential Before Implementing Spravato® in Your Practice
Before adopting the buy-and-bill model for Spravato® (esketamine) nasal spray in your practice, it’s crucial to confirm that the payers in your network are contracted to support this billing method. This step ensures financial sustainability, smooth reimbursement, and optimal patient care. Here’s why payer contracting matters and a guide to the codes providers should confirm in their contracts before ordering Spravato®.
The Importance of Payer Contracting for Buy-and-Bill
Avoiding Financial Risks
In the buy-and-bill model, the provider bears the upfront cost of purchasing Spravato®. If the payer does not reimburse adequately or promptly, the practice could face significant financial strain.
Verifying payer contracting ensures reimbursement aligns with the cost of the medication and associated services.
Streamlining Reimbursement
Insurance companies require detailed coding and documentation to process claims accurately. Without proper contracting, claims may be delayed or denied.
Pre-negotiated contracts simplify billing workflows and ensure alignment with the payer’s policies.
Enhancing Patient Access
Patients rely on providers to navigate complex insurance landscapes. If payer contracting isn’t in place, patients may face unexpected out-of-pocket costs, which can deter treatment adherence.
Maintaining Compliance
Ensuring proper coding and payer alignment minimizes compliance risks, including audits and penalties, by adhering to industry and payer-specific guidelines.
Key Billing Codes to Include in Payer Contracts
Before employing the buy-and-bill model for Spravato®, providers should confirm the following codes are supported and reimbursed by their network payers:
Drug Codes
- HCPCS Code G2082: Administration of Spravato®, first 56 mg or less.
- HCPCS Code G2083: Administration of Spravato®, greater than 56 mg.
Diagnosis Codes
- Common ICD-10 Codes for Spravato®:
- F32.2: Major depressive disorder, single episode, severe.
- F33.2: Major depressive disorder, recurrent severe without psychotic features.
- F32.81: Premenstrual dysphoric disorder (if applicable).
Additional Reimbursement-Related Codes
- Revenue Code 636: Drugs requiring detailed coding.
- Revenue Code 761: Clinic, if reimbursement for the setting applies.
Steps to Ensure Proper Payer Contracting
Conduct a Payer Analysis
Review your practice’s most common payers and their coverage policies for buy-and-bill medications, specifically Spravato®.
Negotiate Reimbursement Rates
Ensure reimbursement rates for G2082 and G2083 adequately cover the acquisition cost, administration, and any ancillary services.
Verify Policy Updates
Payers may update coverage policies periodically. Regularly confirm Spravato® coverage and reimbursement codes are still valid.
Develop a Preauthorization Process
Confirm whether preauthorization is required by each payer and establish workflows to secure approvals before treatment.
Practical Tips for Implementation
- Train Billing Staff: Ensure staff are familiar with Spravato® billing codes, documentation requirements, and payer-specific policies.
- Monitor Claim Denials: Establish a system for tracking and appealing denied claims promptly.
- Communicate with Patients: Clearly explain insurance coverage and potential out-of-pocket costs to avoid surprises.
Conclusion
Ensuring that the payers in your network are contracted to support buy-and-bill for Spravato® is a critical step in implementing this model successfully. By confirming the appropriate codes and negotiating reimbursement rates upfront, providers can protect their financial health, streamline operations, and improve patient access to this life-changing treatment. Take the time to establish these foundations before ordering Spravato® to avoid disruptions and focus on delivering high-quality care.
