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Medical Benefits Billing for Specialty Therapies

Billing under medical benefits is a multi-part process requiring considerable expertise to ensure patients receive optimal reimbursement and access to a specialty therapy pipeline on track for ongoing, exponential growth. Best practices are built on a foundation of a sustained, smooth flow of information among the key stakeholders, encompassing pharmaceutical manufacturers, healthcare providers, payors, patients, and caregivers. The following steps reflect the expertise developed over three decades by Orsini and include:

  • Initial, knowledgeable consideration of benefits for both pharmacy and medical billing
  • Expert navigation of prior authorization (PA) and other utilization challenges
  • Close oversight and prompt processing of claims submissions, and ongoing work with national payor networks to confirm acceptance of therapy on contract
  • A thorough investigation of all potential programs for patient financial assistance
  • Extensive outreach to patients and caregivers regarding reimbursement status

The rapid adoption of specialty therapies for pharmaceutical manufacturers brings extraordinary opportunities and a few formidable challenges. Ensuring these innovative products are accessible to patients, administered, and ultimately reimbursed appropriately can be complex. Especially exacting is billing and reimbursement for specialty therapeutics under medical benefits, a process with a higher risk for adverse outcomes than pharmacy benefit billing.

However, it can also be the best, and sometimes the only, option that enables patients to be treated with costly specialty therapies that account for nearly 50% of a plan’s total drug spend. Currently, 35% of specialty drugs are billed under the medical benefit. A burgeoning pipeline of infusible gene and cellular therapies will continue to flow into a responsive marketplace – the FDA expects to approve 10-20 gene therapies per year by 2025. The result is a projected rise of almost 33% in the number of drugs managed on the medical benefit by 2023. With so many new drugs on the radar, working with a specialty pharmacy skilled in billing under medical benefits is critical to manufacturers’ success. Drawing on Orsini’s long history of expertise, we created a whitepaper to share the five-step process we use for accurate, seamless billing under both medical and pharmaceutical plans for an ever-expanding portfolio of life-saving products.

Download the whitepaper to gain insights into medical benefits billing for specialty therapies.