Top 4 difficulties of opening an infusion suite
Know what to look for now and save trouble later
While the clinical aspects of providing outpatient infusion therapy may not be very different from the home setting, that's not to say there won't be plenty of new challenges for a home infusion provider that opens an alternate-site infusion center.
In last month's issue, Home Infusion Therapy Management looked at how to gauge your potential to open a successful alternate-site infusion suite. In the second part of a two-part series, experts share their tips on the difficulties you can expect when opening such a suite - and how to avoid them.
Karen Flores, PharmD, president of Health Management Association, a consulting firm in Woodside, CA, says your reimbursement staff will need additional training.
"The billing process for an infusion center if you're going through the Medicare model is totally different than what we've been used to under Part B Medicare, where few infusion therapies are covered," she says. "A lot of people don't realize it's an entirely different reimbursement set-up."
"Rules for reimbursement are totally different due to the site-of-service regulations," says Janis Hokanson, site manager of Valley Infusion Center in Los Gatos, CA. "In addition to the regulatory guidelines, the claim forms are completed with different procedure coding. The frequency of reporting is different and the support documentation submitted with claims and the documentation retained in the charts is different as well."
While Medicare will only pay for certain types of infusions, Hokanson notes that for office-based infusion centers, evidence of medical necessity must be present even for fee-for-service and managed care contracts.
"The payers decide whether or not we can treat a patient and which umbrella the care is provided under, and the umbrella determines which rules we follow for the referral and billing processes," notes Hokanson. "Medicare benefits are limited to certain treatments for specific diagnoses, so any diagnosis treated without a proven record of being a covered benefit may be denied. If the therapy is truly medically necessary and proof is available, the denial can be appealed, but the appeals process can throw the cash flow into a lengthy holding pattern. If medical necessity is not adequate, the appeal may also be denied with the possibility of no covered benefit."
"How a physician normally gets a referral or consults drives the infusion suite activity," notes Hokanson. "The referral process for physician practices is governed by the site-of-service rules. In an office-based infusion therapy program, there are multiple entities to be coordinated, and these are payer-driven requirements dictated by the managed care environment."
Hokanson notes that some referrals can involve several physician layers, as well as insurance and case management companies.
"The concept is to sort out which physician is responsible for which process," Hokanson points out. "Sometimes the referral and authorization for treatment can hinge on another practice altogether. I have spent up to three solid hours on one referral coordinating benefits and the individual agencies, and gathering the information they require."
Because there are peaks and valleys in infusion suite cases, you'll likely run into difficulty staffing and scheduling.
Walk-in business wreaks havoc
"In home infusion there is a specific amount of lead time built into the referral process itself, thus allowing time to coordinate staffing requirements," says Hokanson. "In the office-based infusion suite model, a percentage of business is walk-in, so to speak, making it impossible to know what staffing requirements will be needed. The walk-in scenario wreaks havoc on staff productivity and nurse/patient ratio projections."
Hokanson notes that this "walk-in" scenario can lead to wide fluctuations in daily requirements.
"Some days we're inundated with patients, and some days there is only one patient," she says. "Census consistency is one of the complications of staffing."
Other staffing complications include:
· dosing requirements that fall outside normal working hours;
· off-hours back-up situations;
· the need for staff presence whenever the office is open, regardless of whether patients are scheduled.
"The scheduling can be a challenge," says Flores. "Home infusion providers are used to one nurse/one patient scheduling. But in an infusion suite you want to make sure that you maximize the time and billing you get out of the suite."
"Staffing is a nightmare," notes Hokanson. "The key is to base your program on what you want your overall program to provide. If you want to have somebody there so a physician can call at any given time and say, `I've got a person I want to send over right away,' then you've got to have staff there. It depends on the objective and if there is enough revenue to carry you through the slow periods."
Transfusion contract provides steady work
To help address the staffing issue and fill the gaps in any slow times, Valley Infusion has a contract that provides a constant flow of work.
"We contracted with a large medical group to do blood transfusions," says Hokanson. "That is one type of therapy we can provide on an ongoing basis and gives us a steady flow of work, so we know in any given week we'll have at least X number of blood transfusions."
Flores says you must realize that if you are an accredited home infusion provider, your alternate-site infusion suite will subject you to a whole new list of standards.
"If you are an existing, accredited home infusion provider, ambulatory infusion will also be surveyed and becomes part of the overall organization." she says. "So it becomes important when you set up the site to meet accreditation standards."
Michael Tortorici, RPh, MS, president of Dayton, OH-based national health care consulting firm Alternacare of America, says you have to worry about more than just accreditation standards.
"You'll have to follow not just Joint Commission standards, but also life safety and fire codes," he says. Issues such as handicapped parking and access are issues home infusion providers rarely have to worry about. Not so with an infusion suite.
"Buyer beware," says Tortorici. "If you are contemplating getting involved in this, it is imperative that homework be done. The saying `Build it and they will come' doesn't work."