Oct 15, 2024
Apr 3, 2025
Written By Elizabeth Cifers
With as much information as Americans consume daily,¹ skimming has become common practice. We skim social media feeds, internet articles—and often work-related information. Skimming can be a helpful way to quickly navigate to the most pertinent details of a given document. However, there are some places where skimming can get you into trouble. Reviewing the requirements of a drug prior authorization is one of them. Skimming a drug prior authorization may cause you to miss this phrase that could make or break reimbursement for your retina practice: “specialty pharmacy.”
When a drug prior authorization says, “specialty pharmacy,” it means you must use a specialty pharmacy specified by the insurance payer. This means you can’t simply purchase and use the drug to be reimbursed later—also known as "buy-and-bill,” the most common way to bill for retina drugs—but must instead send the prescription to the given specialty pharmacy and have the patient pay for the drug so that it can be shipped to you for injection.
Specialty pharmacy: A source for specialty, high-cost drugs that treat rare or complex medical issues. Insurance payers can require the use of this source of drug acquisition.
Buy-and-bill: A billing process in which a drug is purchased and used by the practice to be reimbursed by an insurance payer later.
Many retina practices must pay more attention to the details instead of glossing over specialty pharmacy requirements in the drug prior authorization process. The result is usually denied reimbursement for a costly buy-and-bill drug…and the swearing off of a skimming habit. In all seriousness, drug denials are expensive—especially when they become a pattern. Most practices can’t afford to lose reimbursement for one drug, let alone multiple drugs, from failing to read the prior authorization approval.
Has your retina practice ever missed a specialty pharmacy requirement or experienced a pattern of drug denials? Retina billing consultant Elizabeth Cifers, MBA, MSW, CHC, CPC, can help you start to catch errors that result in denials before they go out the door. With decades of industry expertise—including 13 years as a retina practice administrator and a role at a leading U.S. eye care consultation firm—Elizabeth has seen it all. She can quickly identify issues that may impact reimbursement. Schedule a free consultation with Elizabeth here.
Source(s):
¹Guttmann, A. Average daily media use in the United States in 3rd quarter of 2023, by medium. Statista. Published June 20, 2024. https://www.statista.com/statistics/1289938/daily-media-usage-us/
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