Retina Consultants of Houston comprises 10 physicians and 10 office locations. At each office, ranibizumab (Lucentis, Genentech), bevacizumab (Avastin, Genentech), aflibercept (Eylea, Regeneron, Inc.), and the dexamethasone implant (Ozurdex, Allergan, Inc.) are administered to a large number of patients. There are several challenges associated with managing a high-volume injection practice. This article details the methods we have implemented to ensure our efficiency, organization, and optimal patient care.

PATIENT FLOW

Because our physicians travel to a different office every day, we cannot assign a particular day as an “injection day.” Therefore, we mix injection visits with new patients, established patients, laser treatments, etc. We also use a customized scheduling template that reserves appointment slots for new patient visits so that injection visits do not take up all of the appointment slots for the day.

Patient flow for injections is difficult due to the sheer volume of patients. We typically designate 1 exam room and 1 employee at each office to handle the injection visits for the day.

DRUG MANAGEMENT

In July of 2006, the US Food and Drug Administration (FDA) approved the use of ranibizumab for the treatment of age-related macular degeneration (AMD). As a result, our practice changed tremendously, mostly affecting our patient volume and injectable drug management. Because many of our patients are injected on a monthly basis, some of whom have bilateral disease, there has been a compounding effect on our patient load. Our monthly injections have quadrupled in the past 4 years. Since ranibizumab received FDA approval, the number of doctors in our practice has doubled, as has our number of employees (now at 85). The use of bevacizumab has continued to climb for AMD, retinal vein occlusion (RVO), and more frequently for diabetic macular edema (DME). It is expected that if ranibizumab is approved for the treatment of DME, our injection volume will continue to increase. It will likely start slowly as we try to determine if there will be any payor issues, but, over time, the volume of injections will be very high.

Due to our number of physicians and locations, it is challenging to monitor, track, and supply each office with the appropriate amount of each injectable. In addition, there may be 3 or 4 subcategories of drugs, such as samples, pharmacy supplied, or free drug (if a patient qualified for assistance); each of these subcategories must be monitored and tracked separately from the general-use supply. As of this writing, we are investigating automated scannerbased and web-based solutions, as opposed to manually counting and inventorying injectables.

Additionally, there are patient-assistance programs offered by pharmaceutical companies and charitable organizations. The process to admit and track patients in these programs is labor-intensive but necessary. One of our employees spends 80% of her time managing and monitoring the patient-assistance programs.

BILLING, CODING, AND REIMBURSEMENT

The billing and coding of injectables is fairly simple once a drug receives a permanent J code. When a drug first receives FDA approval, you must bill payors using a miscellaneous J code, which can cause problems and slow payment from payors, sometimes taking months to get reimbursed. Once a permanent J code is assigned to the drug, however, the billing process and payment is much easier and faster.

Due to the high costs of some drugs, we verify insurance coverage for every injection, which is a time-consuming yet essential process. I have calculated that we must be paid on approximately 20 injections to make up for 1 injection that was denied payment from a payor. In other words, we must be perfect on insurance verification. Although our goal is perfection, it is not always attainable. We have made errors in insurance verification and in not obtaining referrals. It does not happen often, but 1 time is too many when dealing with a $2000 drug.

KEYS TO SUCCESS

The key to our success in handling a high volume of high-cost drugs has been our drug inventory and management, patient-assistance program management, and insurance verification. These 3 areas work together to ensure that each patient receives the best treatment possible, regardless of his or her ability to pay; they also ensure that our practice is reimbursed appropriately so that we can continue to offer the best possible treatment.

Additionally, it is a good idea to keep an inventory log sheet at every location. This sheet should show: (1) the beginning balance of each drug for that location, (2) the name of every patient who received an injection that day, and (3) the ending balance of each drug. Once completed, the inventory log sheet is then faxed to our so-called Drug Czar, the employee who orders our drugs, so that she knows exactly how much drug we have at all of our locations every day. She uses this information to place orders on a weekly basis. This inventory log sheet should also be used to reconcile with your billing system to ensure that every injection is billed and accounted for.

CONCLUSION

As more drugs gain FDA approval for the treatment of AMD, RVO, and DME, the number of treatments administered will increase. Diligently following a streamlined process ensures improved efficiency and a reduced risk of error when managing a high-volume injection practice.

Don Shay, CMPE, is the administrator of Retina Consultants of Houston in Texas. He may be reached via email at don.shay@houstonretina.com.