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Avoid the reimbursement blues


Currently, the most effective treatment for wet AMD is ranibizumab (Lucentis, Genentech), which maintains vision in 95% of patients and improves vision in 40% of patients. However, if mistakes are made when seeking reimbursement for the $2,000 injection, it can bankrupt a small practice. The average treatment plan calls for an injection of ranibizumab in the patient's eye once a month for at least 4 months, and possibly longer. Over a year that can add up to $24,000.

Key Points

Living with wet age-related macular degeneration (AMD) can be devastating for patients. Making mistakes in the reimbursement process for a new drug to treat the disease can be equally devastating for their physicians.

Since receiving FDA approval in 2006, ranibizumab (Lucentis, Genentech) is an effective treatment shown to maintain vision in 95% of patients and significantly improve vision in up to 40% of patients with wet AMD, according to its manufacturer. The average treatment plan calls for an injection of ranibizumab in the patient's eye once a month for up to 2 years.

Although ranibizumab treatment is proving to be a sight saver for patients, reimbursement mistakes can bankrupt a small practice quickly, according to Miguel A. Busquets, MD, FACS, a vitreoretinal surgeon and partner at Associates in Ophthalmology and Associates Surgery Centers in Pittsburgh.


"The reimbursement side is a very important element, just because we're talking about a very expensive drug," Dr. Busquets said. "You not only want to make sure you have something that works, but also that you're able to [administer the drug] in such a way that patients and practices can afford it."

That said, he added that the price of the drug should not keep physicians from treating their patients with the best medication available.

"There are ways to handle the high cost of the drug. An efficient business structure within the practice is the key," Dr. Busquets said. "There are also assistance programs through [the manufacturer] and the community at large that can enable them to afford the medication."

While Medicare, Medicaid, and most private insurers are approving reimbursement for the treatment, Dawn Kalmer, senior manager of corporate relations for Genentech, said the company sees some common mistakes that prolong the reimbursement process. Using inappropriate codes-specifically the temporary J-code that varies by insurance carrier-and inaccurate diagnosis codes can create problems. Ranibizumab should receive a permanent J code in 2008, which will significantly alleviate some of the billing challenges.

The time it takes physicians to be reimbursed for ranibizumab varies by payer. Kalmer said it can also have a lot to do with whether the physician's office follows the insurance providers' processes for claims completing and submission.

In Dr. Busquets' six-office practice, a central finance department handles all reimbursements and insurance issues. Once Dr. Busquets or his colleague prescribe ranibizumab, the finance department counsels the patient about what's involved, what the co-payments will run and what charges can be expected down the road.

A systematic approach

"We handle this in a systematic and organized fashion," Dr. Busquets said. "That's really the only way to go about it."

He added that practices that don't have a targeted person or staff to handle the insurance side of the business can find themselves in a situation where they absorb the cost of the drug because a patient did not go through proper pre-authorization procedures prior to treatment.

"The key is to stay ahead of the game by knowing the insurances, getting the authorizations when necessary, and from that point it's pretty straightforward," Dr. Busquets said.

Another option is to access the drug through a specialty care pharmacy, which some insurance carriers utilize, Dr. Busquets suggested. The system eliminates the middle person-the physician-by having the practice request a drug through a specialty-care pharmacy. The pharmacy then has the burden of filing for reimbursement from the insurance company directly.

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