Beyond Verification: How a Single Detail Can Impact Patient Access and Provider Confidence

When a patient is diagnosed with a rare or complex disease, and prescribed a drug that needs to be infused or injected, the healthcare provider typically prefers to review a medical benefit verification (BV) before scheduling treatment.  One key detail of the BV that helps the provider proceed with confidence—but is often overlooked by many patient services organizations—is the drug acquisition pathway. 

The pathway, which determines how the drug will be obtained, can impact insurance coverage, claims reimbursement and treatment timelines. Ensuring this information is included in the BV ensures the provider can schedule the therapy promptly. 

How the Provider Acquires the Drug Makes a Difference 

Healthcare providers can acquire the drug in one of several ways. 

• From an approved distributor and bill the payer directly (the buy-and-bill model), 

• Alternatively, an approved specialty pharmacy white-bags the drug (usually a single dose) and ships it directly to the provider, 

• Or the specialty pharmacy brown-bags the drug for the patient to pick up and bring to the administering provider (though this is not encouraged as patients often don’t have the knowledge to handle the specialty drug appropriately) 

In recent years, payers have increasingly required the use of specialty pharmacies. As a result, if a provider has purchased the drug and the use of a specialty pharmacy is mandated, the claim will be denied. Buy-and-bill is a more effective approach for the patient—in many cases, allowing them to begin treatment immediately after diagnosis. You can see why this drug acquisition method is preferable to providers.  On the other hand, procurement of the drug through a specialty pharmacy is more administrative work and the timelines are unreliable.  

It’s Complicated 

The rules about the permitted drug acquisition pathway vary by state, by site of care type, and even by individual treatment site. Some payers only allow a limited number of providers within a geographic region to buy and bill causing providers to refer patients to a different site of care adding even more complexity.   

(For more on how the site of care impacts drug access and medical BV, read our blog: To Provide Accurate Medical Benefits, Site of Care Matters.) 

A Best-in-Class Medical BV Provides Detail 

When payer plans include a specialty pharmacy mandate there’s an increased risk of claim denial especially for providers that typically buy-and-bill. That’s why the CareMetx MedeBV solution is the industry leader: It may be the only medical BV that includes this critical detail, helping prevent claim denials for our customers and ensuring patients have faster access. 

Our best-in-class MedeBV processes requests across many payer types to deliver a robust, accurate, rapid response that spells out which pathway is permitted, so providers know their options. As the industry’s most experienced MedeBV provider, we’re always challenging ourselves to deliver more value—and provide a more comprehensive medical BV.  

Delivering BV results that include drug acquisition details, is just one reason that leading specialty manufacturers choose CareMetx. Whether they operate their own internal hub or use our hub services, they’re driving better drug program results by leveraging our deep expertise in medical benefit verification - an industry-leading technology.  

Schedule a consultation today to learn how our comprehensive BVs and other technology-enabled services help you achieve your drug program goals.