What is Buy and Bill?

Buy and bill is the traditional distribution and reimbursement model for specialty drugs.

In this model, the provider purchases the drug and administers it to the patient. Once the drug has been administered, the provider then bills the payer.

Assessing Patient Coverage

A provider’s decision to prescribe a drug is often influenced by the patient’s insurance coverage. Providers have to consider if the drug is covered by the patient’s insurance, if there are any utilization restrictions in place, and the patient’s out-of-pocket cost.

Reimbursement hubs are one tool that providers can use to help maneuver the buy-and-bill process and assess patient coverage. Reimbursement hubs offer a wide variety of services to providers, payers, patients, and specialty pharmacies.

Review the list to see some of the services reimbursement hubs provide.

 

 

 

 

 

 

 

 

Procuring the Product

Providers typically do not order specialty drugs directly from the manufacturer.

Procuring specialty drugs usually involves several stakeholders: specialty wholesalers,

full-line wholesalers, and group purchasing organizations (GPOs).

 

Select the images to learn about stakeholders involved in the procurement of

specialty drugs.

 

 

 

 

Administering the Drug

Once the specialty drug has been procured by the provider, it can be administered to the patient. There are different types of sites of care where specialty drugs are administered.

Select the images to learn more about specialty drug administration sites.

 

 

Billing the Payer

Once drugs have been administered, the billing process begins. Billing may be done electronically, by paper, or both, depending on the provider’s processes and the policies of the payer being billed.

Because billing policies and practices can vary from one provider to another, and one payer to another, the use of codes to identify services and products and request reimbursement are essential. There are two main types of codes:

• Diagnosis codes

• Procedure and product codes (Healthcare Common Procedure Coding System

[HCPCS] codes)

 

 

 

 

 

HCPCS codes include two subsets of codes, Q-codes and J-codes.

Select the icons to review the differences between Q-codes and J-codes.

 

Receiving Reimbursement

Reimbursement rates and how reimbursement is received varies depending on the type of payer being billed.

Select the icons to review reimbursement processes for different types of payers.

 

 

 

 

 

 

Trends in Buy and Bill

As the healthcare industry continues to transition from a volume-based care model to a value-based model, how and where specialty drugs are administered is changing as well.

Select each image to see trends in buy and bill.