To Provide Accurate Medical Benefits, Site of Care Matters

For patients requiring specialty medications, the care journey can be especially challenging. The more complicated the treatment administration plan, the more crucial the benefit verification (BV) process becomes, especially when the site of care differs from the prescribers’ location. 

CareMetx understands these challenges and addresses them by accounting for the disparate scenarios that patients encounter when prescribed specialty drug therapies, by implementing BV strategies that facilitate timely access - regardless of where the patient receives treatment. 

Overcoming Site of Care Hurdles   

Many factors can impact a patient's benefits, such as their health insurance payer, plan, group, and the site of care where they receive treatment.  

When a patient’s treatment plan includes a healthcare provider (HCP)-administered therapeutic, such as an infused or injected drug, the prescribing HCP may refer the patient to a different site of care for the treatment to be administered. In this scenario, it is essential to verify that the patient’s insurance plan covers the specialty medication at the chosen site of care. 

There are two scenarios in which the site of care choice can impact patient access and out-of-pocket (OOP) costs, as well as the reimbursement to the HCP: 

1. HCP or Patient-Driven choice of a Particular Site of Care: Some HCPs prefer not to administer treatment at their location because they don’t want to stock the medications and take on the reimbursement risk, so instead they refer patients to other sites of care.
   
   Even if the referred site type (e.g., hospital, clinic, or infusion center) is covered by the payer, individual facilities often have different contracts with varying coverage rules. For example, benefits can vary between an office (site type 11) and an outpatient hospital (site type 22). Without a thorough BV process, both the HCP and the patient might encounter unexpected issues. 
2. Payer-Driven Decision to Use a Particular Site Type: Sometimes, payers will only cover treatment if it is administered at a specific site type (place of service), such as an infusion center. Cost is usually the main factor in this decision, but state regulations can also play a role, as some plans in certain states prohibit treatment at specific types of facilities (site types). 
   
   If the patient receives an HCP-administered therapeutic at an unapproved site type, the payer can deny the claim, leaving the treating HCP with an unreimbursed expense or the patient with a high out-of-pocket cost. 

Ensuring Smooth BV at Any Site of Care  

Regardless of the prescribed therapy or site type, specialty drug manufacturers need confidence that patients can access and afford their medications. That is why CareMetx takes measures to provide that assurance as part of the BV process, handling the prerequisite steps quickly and efficiently.   

An effective BV process will first confirm whether the payer’s policies include restrictions on the site type at which the patient can be administered the prescribed treatment. Once it’s clear that the chosen site type (for example, an infusion center) is covered, the process moves on to verifying the specific benefits that will apply if the prescribed medication is administered at the chosen site of care (for example, the specific infusion center near the patient’s home).  

At both steps, CareMetx applies best practices proven to increase the speed to therapy and provide an accurate result. By delivering BV results in seconds instead of days across many payer types and sites of care, CareMetx removes administrative hurdles that often stand in the way of getting patients on therapy quickly. In turn, that improves patient experience. It can also help boost therapy adoption by HCPs, who appreciate that the manufacturer has taken steps to reduce the administrative burdens that plague most medical practices today.  

As a leading Digital Hub that handles over 2,500 transactions daily—and half a million during benefit reverification season—CareMetx is uniquely equipped to accelerate speed to therapy through fast, reliable BVs. Our proven approach to benefits verification reduces wait times and removes access barriers so patients can receive their prescribed treatments. This is why premier manufacturers turn to CareMetx for flexible, scalable patient services programs and best-in-class technologies that improve therapy initiation, persistence, and adherence.  

Contact CareMetx to learn how our Digital Hub can drive better results for your drug program.