Aug 29, 2024
Apr 3, 2025
Written By Elizabeth Cifers
In a world where every penny of potential reimbursement for medical services matters for the ongoing success of your practice, retina specialists must have a solid grasp of drug step therapy. Following insurance payer requirements for step therapy is critical to receiving compensation for retina drugs purchased and injected. Learn what step therapy is, how it works, and common pitfalls often resulting in denials on retina drug claims.
Step therapy is a common requirement before using branded drugs among Medicare Advantage and commercial insurance payers. It may or may not be accompanied by a prior authorization requirement.
Generally speaking, step therapy means trying a lower-cost drug before “stepping up” to branded, more expensive drugs. The lower-cost drug—often called a “first line” or “preferred” drug—must be adequately attempted and “fail” from a medical standpoint before a more expensive drug can be prescribed. The key term for failure is “medical.” As we recently discussed in an article on retina drug prior authorization, the reason for drug failure must be medical and not based on preference or convenience—and it must be documented appropriately.
Step therapy is a way for insurance payers to keep costs down. Other terms for drug step therapy include “try-and-fail” and “fail first.”
Each insurance payer may have different policies for step therapy. Some might say retina drug “A” must be attempted before retina drug “B,” and others might say retina drug “C” must be tried first, then “A,” then “B.” Reviewing the specific drug policy for the insurance payer you’ll be submitting claims to and expecting payment from is a must.
Retina practice consultant Elizabeth Cifers, MBA, MSW, CHC, CPC has seen many denials resulting from failure to meet insurance payer step therapy requirements over her decades in the industry. Reimbursement for a retina drug can be denied even with prior authorization. Note: providing a sample of the desired branded drug does not constitute step therapy.
Reimbursement is the lifeblood of your retina practice. Denials add up, even for something as “small” as “low-cost” drugs. Understanding insurance payer policies for step therapy will help ensure you receive compensation for the services you provide and maintain a healthy bottom line.
If drug denials have become a pattern at your retina clinic—or you’d like some help with drug claims—consider a conversation with consultant Elizabeth Cifers to explore potential synergies. Elizabeth offers a range of professional services on the business side of retina, leaning on decades of industry expertise. She started a consultancy to maximize the revenue and efficiency of retina practices across the country, and she’d love to help you. Book a free consultation here.
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