In this episode, Dylan McCabe and Reece Norris interview Stef Parks and Angie Baker from Xcenda. Angie and Stef spend their days at Xcenda helping physician offices navigate the challenges of specialty medication reimbursement and utilization controls by insurance companies. Listen as Stef and Angie share their perspective on the specialty reimbursement landscape.
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Transcript: How to take the confusion out of infusion billing with Stef and Angie
Dylan McCabe: WeInfuse Podcast episode number nine, welcome to the We infuse podcast, where we take the confusion out of fusion and each week We give you a behind the scenes look at the infusion practice from a clinical side. And from a business standpoint, we also interview industry experts. And this particular episode, we’re actually going to interview Stephanie Angie. They are infusion billing experts out in the field, helping practices and clinics, optimize their billing issues and challenges. And it’s going to be a really good interview because you guys are going to hear two things, their expertise, as they explained, kind of the details of what you face when you have an AIC and ambulatory infusion center versus a home infusion practice and the differences in billing and revenue cycle management, stuff like that. You’re also going to hear their passion for patient care and how really helping patients with these issues is a game changer. So without saying any more, I’m just going to jump right in. And here we go with the interview with Steph and Angie, listen in. Okay. As mentioned today, we have special guests on the show, Angie Baker and Steph Parks billing, and reimbursement specialists with a history in infusion billing. So ladies, thank you for being on the show.
Angie Baker: Thanks for having us.
Dylan McCabe: All right. And Reece is our co-host today as well. And Reece has a history with these ladies as well or at least with Steph. So this is going to be interesting.
Reece Norris: I’m excited, Dylan. It’s fun to be back in a room with Steph to talk about infusion. Steph Parks was our infusion, billing manager, VP of reimbursement, if you will, for quite a while, for five years when we were a manager of infusion centers. And even when we transitioned over to being a standalone infusion center company so we were excited to have her back and she’s sharp as they come in this world.
Steph Parks: Thanks Reece.
Reece Norris: Yep.
Dylan McCabe: So you, you, you entrusted her with some of the most important details of the business.
Reece Norris: Absolutely. Well, why don’t you guys give a little bit of your background just in the infusion industry and experience in billing, just so our listeners kinda know where you’re coming from?
Steph Parks: Okay. Well, I’m Steph and I have a long background in practice management, with a focus on infusion therapy. And currently I am in the pharmaceutical space as a field reimbursement manager.
Angie Baker: Awesome. I’m Angie Baker. I have about 15 years experience. My background is a high emphasis in home infusion, revenue cycle management, practice management, sleep medicine. So a variety of different healthcare settings, but all, revenue cycle so my current role now, again, is consulting in the field with specialty medications, doing patient access to ensure patients get access to therapy quickly.
Dylan McCabe: And that’s awesome. And usually when I’m interviewing somebody, my next question is what’s your main area of expertise, but I think everybody has a pretty good concept that you guys are experts at billing and revenue cycle management. And that’s exciting to me because when we talked to practices all over the US this is the number one challenge they face. I mean, yes, everybody wants to take great care of patients. An infusion suite is a different business model, but the risk or the scary part of it for a lot of providers is the billing and the revenue cycle management aspects. So we’re just really glad you guys could take the time to be on the show. What would you want your listeners if there was one thing, I mean, revenue, cycle management and billing for infusion and all these things. It’s a, it’s a broad concept, but if you could distill that down to one big thing, you would want our listeners to know about your specialty, what would that be?
Angie Baker: I think revenue cycle management regarding that is incredibly difficult to get these patients access to medication from, the very beginning of doing a benefit investigation that sometimes can take 45 minutes. And then the next step of doing a prior authorization, ensuring that we are capturing the correct units on whatever drug that it is that you’re billing for, that doesn’t even come into play of billing it correctly. You have to ensure that you have experienced billers in your clinic. If you’re not billing correctly or capturing all the units, I mean, sometimes that could mean $10,000, if you’re billing and collecting it. So, just ensure that you have certain protocols in place in your office, great experienced people, just to ensure that you are being reimbursed for that. And then again, ultimately the most important piece of that, or, who is involved in that is the patient. This is lifesaving medication for the most part. But you have to be able to have providers be able to provide that service. And, can’t do that if you don’t have, all of your processes in place.
Steph Parks: And additionally, just to piggyback off of that, as far as the patient access goes, that piece of it, step therapy is something that we see everyday and we are trying to overcome all of these hurdles so that we can get patients, medications expeditiously so that these patients can feel better. Some of them are quality of life medications. So, if I could just give one piece of advice to somebody who’s going through that sort of thing is, I mean, expect those challenges and sort of, find a way to work around them. We definitely have to get creative sometimes in our roles and, to Angie’s point to, making sure that those authorizations are clean, so that your infusion billing, if that’s the drug that you’re billing is appropriately, cause that definitely can be a make or break, financial situation for, any infusion center.
Reece Norris: When you say get creative, are you talking about getting patients connected with, co-pay assistance programs?
Steph Parks: Absolutely.
Reece Norris: New meds, for example.
Steph Parks: Absolutely. And a lot of the manufacturers will offer different types of assistance for different payer types. And so like, just like you mentioned copay cards or, patient assistance, those types of situations, if a patient can’t get the medication through a payer, definitely explore those options. Yea that website is very valuable. Needymeds.org is one that we’ve used for decades. So yea that definitely and also, just getting on the phone and trying to sort of just get your point across the payer a lot of the time it’s somebody else sitting on the other end of that phone and they don’t understand how sick the patient is. They don’t understand how badly the patient needs the medication. So, getting the clinicals, getting that information across to the payer I mean, sometimes that can be a huge difference and can mean, the difference between an approval and a denial.
Reece Norris: Steph, when you were working with our team in, I guess it was your team, technically are just remember you guys always going above and beyond meeting. if you got no on the front end or the first answer, you don’t just stop there and you guys were constantly being creative to your point and then just, never giving up on behalf of these patients. And I think that’s what makes it, that sets infusion centers apart, and can set your infusion center apart if you’re really going the extra mile for these patients. I mean the insurance company, they may say no just out of the gate, but if you fight for your patient, a lot of times you can get it approved.
Steph Parks: Right absolutely.
Angie Baker: That’s definitely. And then our role, we provide a lot of education, a lot of proactive education in these offices on how to fill out the PA form. What does that website do to that payer? If that drug is denied, do we have to switch therapy? No, most of the time we can do an appeal, what are the resources there. So, we’re very passionate about ensuring that, if a physician prescribes a certain medication that we know how to get it covered and these offices know how to get that covered, so
Steph Parks: Right, breaking through those barriers.
Dylan McCabe: That’s awesome. Well, it’s, I mean, it’s clear you guys have a passion for the patient, and I think if you lose that perspective it’s just going to be another task you do every day at your job. And I think a lot of these people that you even speak to at the payer, they lose sight of that. They, like you mentioned, lose sight of that patient that’s getting that life changing therapy. And I mean that’s what makes me passionate. And I have it’s my job to sell our software right. And help implement this software into offices. But my passion is knowing that the software helps the provider because it streamlines this incredibly complex business model. It also helps the patient because in our infusion nurses charting area, it really forces best patient care and best practices in a clinical setting. And it’s awesome to know that you’re actually making a difference in people’s lives. And that’s cool that you guys are coming on the number side to make sure billing and revenue cycle and all that stuff, but it really is still all about the patient. And, that’s just great. So well, knowing that you guys are in that, and you, you consult with different offices and, and help these practices get on top of their revenue cycle management. And you’re trying to bring about the best or the best result with patient access. What would you say has been maybe one of your biggest challenges, if there’s a story that comes to mind or just a situation that’s really challenging in that regard?
Angie Baker: My prior, prior roles, I wouldn’t say maybe a challenge, but maybe like a light bulb moment, like you had mentioned earlier is, whenever you’re a provider, a service and you’re purchasing these drugs that are so incredibly expensive and you’re looking at the way that these different contracts reimburse, and then you’re looking at the way, if you have a self-pay patient come in, what would that price be? But, and then just looking at the different ways that the reimbursement landscape has changed within the last 10 years. I think at this time, it is so incredibly important to have some sort of either protocol or processes or whether it be technology in place that really puts those safeguards, that kind of helps ensure that you’re not going to lose money whenever you’re providing this. So it’s, that would be something that is, has been a light bulb moment for me.
Steph Parks: And Angie is right, just to piggyback off of that too. knowing the payer landscape, knowing, kind of being an expert in that field, knowing if you need to go especially pharmacy versus buy and bill to, save yourself some, a little bit of heartache with on the reimbursement side and making sure that you have those processes in place so that, you know exactly what the protocol is going to be. And I, I do know, history with, innovative, we had, several drugs that were very difficult to get reimbursed on. And so we just made it a company policy that we wouldn’t buy and bill those drugs at those particular drugs. And it wasn’t many, but those particular drugs would have to go through associate pharmacy. They were either extremely expensive or very difficult to be reimbursed, or when they did get reimbursed, they didn’t really even cover the cost of the medication. So, to Angie’s point, I definitely agree. It is so important to have those types of protocols in place.
<>Reece Norris: Yea we did that for newly launched drugs. A lot of times they saw the miscellaneous J code. So J3590 or J3490 and so, at innovative infusions, that stuff just mentioned where we both worked we would, we would have these policies where, you would for new drugs that are being launched because the reimbursement was still questionable. There was still a lot of enigma around what we’re going to get paid. We would, force those patients to use specialty pharmacy or that was a company policy for us. Another thing that we did at innovative was we had full revenue cycle billing managers. And I think for us, it was a strategic decision to do that and not silo the different steps and reimbursement up, you know? So some, some folks, and again, there’s no right answer here, but some folks are like, Oh, these folks verify the insurance, these code, the claims, these are the AR specialists, but for us at innovative infusions, when we owned and operated it, we really had full revenue cycle managers, meaning they did every single step and they get, you really get to know the patient that way. I mean every single thing about that patient’s insurance. And if you do the work right on the front end, the back end is a lot better. And for me, as a leader of that organization, I was able to go to one assess team members and say, Hey, what’s the issue with this patient? Why do they have an AR balance? And they really had to answer the question. They couldn’t say, oh, well, they didn’t verify it right. Or that department didn’t do something right. So it was really all there. There was a lot of accountability in the process.
Steph Parks: And no passing the buck.
Reece Norris: No, there was no passing the buck. Yeah. Because it is a very complicated process now, again, there are a lot of reasons why you can argue the other way. Like you can develop specialists in departmentalizing, everything, but we found that it was best to do full revenue.
Angie Baker: Right. And additionally, our billers, then our billing account managers, as we called them, were also able to develop that relationship with the patient. So, it wasn’t just, it’s another Remicade or it’s another IVIG it was that patient and their therapy. So it became really personal, if there was a denial and I can remember a specific patient even, that was on IVIG treatment and then exhausted kept has benefits. I mean, that is a very expensive treatment and the patient was on a very large dose and it was, I remember it was a two, two day treatment even, and he capped his benefits and they wouldn’t pay for it any longer. So we had to figure out, I mean, it was this patient, he needed this medication. So we had to figure out how to get around that and figure out how we could get him covered additionally. And, we ended up doing that. It was a crazy process, but again, it came back to that patient, it was so important to have that patient back in the clinic and mean he was of course elated because he needed the medication. So, yea it definitely makes it more personal and the follow through is, is amazing, because those, those people that you hope that are so passionate about patient access are the ones that are handling those accounts.
Reece Norris: And I’ll add to that even further. So rarely did the phones get back to me, but if they ever did and a patient was on the, on the other end of the line, and I would say, well, how can I help you? This is Reece, how can I help you? And there would be like, Oh, I’m trying to reach Steven or Kim. And I was like, well, they’re out to lunch. Well, I’ll just wait till they get back. And they know my account well, and I would have been able to help them anyway, but I would have taken good notes, so somebody could have followed back up. But long story short, I think that just goes to prove that, if you have a high level of service, these patients are, they get comfortable talking to that billing account manager as we titled that person. And they want to, just wait to talk to [inaudible]. And when we did have attrition, which was not often, it was sometimes family, the patients were so used to their billing account manager. So not only are they making a relationship with a nurse, they’re making a relationship with the financial piece of the business as well.
Steph Parks: Right. I think for a lot of these patients, I mean, they’re on therapies sometimes for a lifetime. So I mean they’re coming back every month.
Reece Norris: And they want that consistency.
Steph Parks: Right. For sure.
Dylan: It’s huge. And it’s, it’s just, I mean, anytime you experienced that feeling that you don’t matter, or that you’re just another number, that’s a terrible feeling, especially when it involves your own personal health. So that’s just great that you guys are focused on that and have stories about that. I had a plumber come to my house and I mean we were talking it up. He was there for, I think he was there for an hour and he’s like, well, is there anything else going on? Like, man, to be honest, here’s this issue. He started looking at everything and then at the end of it all, he’s like, man, I’m not even going to charge you for that. You, you didn’t realize you had that issue. And that was easy and I was like, it was like, wow, is this really happening? This person really cares about me and really just wants to do something good. It’s just a, it’s just a remarkable feeling. So it’s just so neat that you guys are focused on that. Let’s now mention a light bulb moment a little bit, but let’s get into the difference because we talk with practices all over the US and we also get a lot of calls from people that are already in like home infusion or on the pharmacy side. And then they want to have an infusion practice and they think, oh, this could be a business we could start. It’ll be really easy. Cause we’re already clinically trained. We’re already doing the home infusion thing. How different is it to go from home infusion to the standalone infusion suite or ambulatory infusion center as far as billing and revenue cycle management goes?
Steph Parks: Well, I’d say at the start of care is probably the, one of the biggest differences outside of, the different ways that you bill home infusion. So with home infusion, you’re getting patients that are discharged out of the hospital. Sometimes you will have a day’s notice sometimes you’ll have 30 minutes’ notice. So it really makes a difference whenever you’re having to verify benefits, get an authorization, look at all of that home infusion wise. But the process of getting things approved is the same. The billing is a little bit different, just different places, service different benefit category, especially with Medicare. There are some drugs that are covered, in the home and then most, very few that are covered in the home, mostly are covered, in the office. So, for the ones that are covered in the home, very strict guidelines that you have to, that you have to look at. So, one of the big things that changed with Medicare, regarding infusion and infusion patients, you’re aware of Medicare part D of course. So yea, 2006, Medicare part D comes out. They have a benefit for drugs now. Well, infusion drugs were left out of that benefits so, the supplies anyway. So, high anticipation of getting coverage for these patients most are on a fixed income, of course, they’re Medicare age. So whenever it rolled out, yea you have coverage for your drug, which went through the PBM, but you still have to pay out of pocket for your supplies, and that still is the way that it is. So, that’s one of the huge hurdles, but the difference in, I guess billing wise is just, you’re billing just at different places, service basically.
Reece Norris: And that’s, so from a consulting perspective, we infuse, we have obviously the technology piece and while we don’t advertise consulting, we get a lot of consulting, I guess, gigs or engagements. and so one of the things we often struggle with in terms of communication, or you can’t be clear enough to a home infusion pharmacy that wants to operate a infusion center as a place to service and making sure that if they want to go in the biologic infusion space, you really need to be placed in service 11, which is clinic or our office. And I mean, we hear it a lot, but it’s basically a physician office places service, not that you have to have a physician, you can use nurse practitioners and some States, a physician assistants, but again, we always end up having to beat that, that drum quite a bit, Hey, making sure that you’re not billing as a, infusion suite to a home infusion pharmacy, you’re truly a separate place to service, a separate tax ID, in many instances, so
Steph Parks: Certain contract type as well. And I think, one of the big differences of course, with home infusion and, being infused in the office is just, it’s a different set of different set of drugs are so many drugs that can be infused in the home that, and just the convenience of it in your home as well. And then there are drugs that can’t be infused in the home that have to be infused in the office. So,
Dylan McCabe: Yup, yup. Minor differences can make a big impact on your bottom line margin, the margins, what they are, the numbers, what they are for those specialty biologics. Well, tell, tell our listeners, what are some things you guys are most excited about right now and infusion and everything that’s happening as far as it pertains to revenue cycle management and billing and what you guys deal with on a daily basis?
Angie Baker: Well, I am super excited about, I mean, of course I have a huge passion for patient access. And that is seriously what drives me every day. I’m super excited about the potential changes in the payer landscape. I’m excited about the potential, for, step therapy to sort of go away at some point, we can all dream, right. But also, so I feel like, going through the process for appeals and, sort of following those guidelines definitely help change those landscapes. So, just doing what we do on a regular basis, with our patient in mind, pushing for the patient to have therapy quickly, and going through those proper channels, I definitely feel like that is going to have a huge impact on the payer landscapes. And I’m hoping at some point we’ll reduce the hurdles that these patients have to go through.
Steph Parks: Yea most definitely. There’s a lot of legislation right now to reduce step therapy. And I think Texas is one of the States that has passed that recently. We looked at it at our last national sales meeting. I think there’s about six States that are either passed something or they’re getting really close. So that’s a huge win for our patients.
Dylan McCabe: And so for people that are listening and don’t know what step therapy is, how would you describe that?
Angie Baker: So step therapy would be, if a patient is prescribed a particular drug, but the payer says they will not cover that until the patient has tried and failed other therapies. Sometimes there’s two sometimes there’s four it just depends on whatever the preferred medications are for that particular payer.
Steph Parks: And that’s pretty, that’s pretty standard that it doesn’t really impact the patient that much if they’re newly diagnosed and new to that drug category, but where it really, affects the patient as say, they’ve been taking a particular drug for a year and then their insurance changes well their new insurance says, well, you can’t take that drug anymore. You have to take these other two. Although they’ve been taking the drug for a year, it’s doing good. We know that he’s not this patient may not react well to the other drugs. So there have been instances where, these offices may not know, Oh, I can, appeal that denial with the payer. And then that patient will go and try those other drugs and then ultimately have to go back onto the therapy. So it really is it really affects the patient in a negative, negative way.
Dylan McCabe: And so what is the benefit to a step therapy strategy? Is it to try to keep the patient from taking the most expensive therapy right away?
Steph Parks: Well, I, I think that there’s different. I think it’s, it’s different for different payers. I think that maybe some of the drugs that they would view as more efficacious cause they’ve been out longer. Potentially I mean, I, and I don’t I can’t really speak on that. I haven’t ever, I’ve not been on that side of the payer, but, I mean, I would guess, drugs that have been around for some time and that have sort of patients have done well on them, they have a great track record kind of situation. That’s really what I think, what I see regularly, that’s what I think drives it most of the time. And it could be a, a payer, it could be a cost, thing too, but, I don’t know.
Reece Norris: Yeah. So, like when Intivio was launched, for example, it’s a drug that treats crowns and an infusible drug that treats crowns, it went through several iterations of step therapy across different payer landscapes or in different payer regions. They’re used to Remicade, they’re used to, Humira, Embrel self injectables. And so, it’s just a way to tighten that formulary. Hey, try these first, before we approve this new drug, cost containment for the payer. Sometimes rebates come into play, right? If a manufacturer is giving a drug, a rebate to the payer, which may or may not go away depending on what this administration does, but yea there’s a lot of factors that go into it.
Dylan McCabe: And so, and that’s why I love being the host of this podcast because you obviously, I know our software, right. But you guys have such a nuanced specialty inside of the infusion world. So I get to ask these questions and get good answers on them, but it seems like the, so the biggest challenge is that you may have a patient that’s been in therapy for a year and their insurance changes and then they have to get off of it. That’s the biggest issue if I hear you correctly.
Angie Baker: Right.
Dylan McCabe: You think common sense would say, don’t do that.
Angie Baker: You would think. Yeah. And, Steph and I will go in and educate these offices whenever we see that happen and say, no, you don’t have to switch your patient. Let’s work together. I can show you how to work through that with the payer,
Steph Parks: Continuity of care is a lot of the, some of that will go away with continuity of care. But yeah, just trying to educate the offices, you do, you definitely do have to start all over whenever there’s a new payer involved. And, sometimes that can prove to be incredibly frustrating for the patient, especially if, like Angie was saying, they’re doing well on the drug already, and then they have to step back and it’s not covered any longer. A lot of these drugs are so expensive and patients can’t afford to pay for them out of pocket. So, there’s kind of a really urgent need to get through that process quickly.
Reece Norris: And if you want more information, this is a really a big topic for the national infusion center association. So visit infusioncenter.org, we really outlined step therapy. What, NICA is what we call that organization. So what NICA is doing there, NICA or NICA is what we call it. In terms of, advocating for patients to reduce barriers, to reduce step therapy mandates, in all States. And they were actually, I think they wrote the legislation for Texas or helped write the legislation For Texas.
Dylan McCabe: well that is so good. So, well, there’s so much we could talk about and you guys could easily just rattle off all these really detailed answers, but, we don’t want to turn it into an hour and a half long podcast. So what’s one kind of last parting piece of advice for our listeners?
Angie Baker: Just continue to advocate for your patients. I would say, take any opportunity that there is to go the extra mile, do the extra education that you may have to do, spend the extra time, and that aspect so.
Steph Parks: I’m totally there right there with Angie. Again, we have a huge passion for patient access. So definitely push through those barriers and follow the process, so that patients can get on medication and hopefully we can get legislation changed so that we don’t have to jump through as many hurdles.
Dylan McCabe: That’s so good. Well, Steph and Angie, thank you so much for being on the show. All right. That sums up our interview with Steph and Angie. We hope you got a lot out of that. And if this has been helpful to you, definitely like, and share. If you see this on LinkedIn or on our Facebook page, if you could take the time to rate and review on iTunes, that would be great. We love seeing those reviews and that helps us to get the word out. And then also if you haven’t done so yet definitely check out our blog. Bryan and Reece really are experts in the infusion space and they write blog posts and we post those on our website, check out our blog at weinfuse.com and just go to that tab that says IV insights. And you can read the latest articles, many of which have to do with billing, NDC billing, talking about the different issues in billing in the infusion suite, and even providing formulas for doing that correctly. And if you haven’t done so be sure to request a demo of our software, to learn how we infuse can take the confusion out of your infusion practice and schedule a short demo meeting that takes 30 to 40 minutes to see the best platform out there for managing the entire infusion practice workflow. Just go to weinfuse.com and schedule that demo today. All right, guys, this is Dylan McCabe with the, we infused podcast. Thanks for joining us. And we will catch you in the next episode.
Guest Speakers:
Field ReImbursement Managers at Sun Pharma, Stef Parks and Angie Baker, are infusion patient access experts with over 20 years of experience. With a BS in Healthcare Administration/Management, Stef has worked in neurology, cardiology, oncology, and more. Angie worked in specialty and home infusion management for over 10 years before joining Sun Pharma.
