Fee schedules are a pain point for all practices. There are numerous payers, copious and undefined...
Stop me if you have heard this one before. “Hey doc, I saw a commercial last night about a new drug promising great things, I want THAT drug!”
Now comes the fun part of explaining to the patient why or why not this particular medication may be appropriate for them. Unfortunately, that is only half the battle. Even if the patient is a good candidate for the drug, can your practice afford the potential risk that comes with prescribing a new to the market medication?
Unlisted/unspecified codes (NOC – Not Otherwise Classified) share the same temporary code, unclear reimbursement, and many times insurance payers are not prepared for them. This creates extremely long lag times in reimbursement wrapped in all kinds of administrative burden. What’s the right thing to do?
J9999 Pharmaceuticals: The Problem Explained
All oncology practice administrators juggle the clinical and financial implications of any decision, looking at issues and opportunities through both a patient-centric and a business intelligence lens. Admittedly, there can be tension between these two lenses: the best decision regarding patient outcomes is not always the most business-savvy choice, and vice versa.
Of course, these decisions are rarely, if ever, entirely black and white choices of right or wrong. They exist on a continuum, which is what makes the decision-making so challenging.
All this is true when considering J9999 pharmaceuticals. They’re a necessary evil in practice management: offering revolutionary new therapies for improved patient outcomes while being incredibly frustrating in terms of billing and timely reimbursement.
We have seen huge impacts on timely reimbursements, causing outstanding AR attributed to the use of unlisted J Codes. In one community practice, over 30% of claims utilizing newly indicated immunotherapies took longer than 90 days to be reimbursed, even worse, over 12% was still lingering in AR over 365 days later. When considering how much pharmaceuticals are purchased for up front, these impacts on timely reimbursements can certainly add up to major losses.
Manual Narration Equals Delays, Underpayment and Nonpayment
Manual narration for unlisted J code pharmaceuticals is the only way to get the claim out the door yet it doesn’t always lead to accurate reimbursement.
Payers generally take longer to process unlisted J code claims because of the added complexity of doing so. There’s also a greater likelihood of underpayment as it is common for the narrated billable dose to be overlooked and the pharmaceutical reimbursed as a single unit.
When practices fail to notice this discrepancy, they lose out on revenue. Even when the practice catches it, they’re missing out on that revenue until an appeal can be filed and appropriate payment received from the payer.
The Dilemma for Oncology Practice Administrators
All of this adds up to a dilemma for oncology practice administrators. When a new pharmaceutical comes available and is shown to be clinically superior to the traditional therapy, patient-centric care leads you to use that pharmaceutical.
But it isn’t always that simple. There are no specific billing guidelines on this new pharmaceutical. There is no guaranteed timely reimbursement and a practice can nearly plan on delays in reimbursement due to the manual nature of the claims.
For some pharmaceuticals there are manufacturer/distributor programs that allow for delayed dating or the drug being provided on consignment. But eventually, a practice will be left with a bill for the drug and an unlisted J code. And therein lies the dilemma.
Best Practices Surrounding Unlisted J Codes
Ultimately, patient-centric care takes precedence over the many difficulties with unlisted J codes, but there are ways to minimize the risk of using these pharmaceuticals. Below are six best practices that we’ve identified when using unlisted J codes.
1. Establish a Policy with Criteria for Use
The first best practice is to set clear guidelines and establish a documented policy for when J9999 pharmaceuticals can or should be used in a practice.
For example, a practice might choose to limit J9999 pharmaceuticals to scenarios where the efficacy and/or toxicity profiles are superior to the currently established products. They might also restrict use to only the indications defined on the pharmaceutical’s package insert. Lastly, practices might want to have medical director or administrative approval whenever an unlisted J code product is ordered. All are individual practice preferences to address care and cost considerations surrounding the use of unlisted J code pharmaceuticals.
2. Educate the Revenue Cycle Team
Everyone on the revenue cycle team needs to understand the unique circumstances of a J9999 category drug. Each team member should be educated on product-specific indications, route of administration, clinical use cases, required pretreatment testing, and anything else called out in the package insert.
Crucially, the team also must know and understand the available payer policies and the documentation required to meet those policies. Patient Advocates need to be educated on patient financial resources that may be available for this new pharmaceutical, and be sure to leverage pretreatment enrollment for applicable patients.
By taking these steps, a practice can minimize the costs incurred by the patient and practice alike, lowering or eliminating the frustration and financial risk of using an unlisted J code pharmaceutical.
3. Address J9999 Utilization and Reimbursement Guidelines in Commercial Payer Contracts
While this won’t always be possible, a practice should address J9999 utilization and reimbursement guidelines in commercial payer contracts. If a practice has a written agreement for how an insurance company will handle J9999 scenarios, they are much more likely to be appropriately reimbursed.
This point becomes even more pressing when you deal with Oncology specialty drugs which are high dollar, high complexity products. Ensuring you have guidelines included in your commercial payer contracts can greatly reduce the headaches later on.
4. Monitor the Data Surrounding the J9999 Therapy Delivered
As closely as possible, a practice should monitor the data surrounding the J9999 therapy that was delivered. It is just too risky to let these claims flow through on autopilot. Every aspect must be monitored: the Medicare rules surrounding J9999 drug reimbursement, the specific commercial payer policies, the anticipated payment for the dose delivered, the actual cost of the dose delivered. The actual dates of service along with the primary and secondary payments received.
As labor intensive as this might seem, it is this kind of intense monitoring that leads to a successful and accurate reimbursement.
5. Ensure Payer Reimburses for Correct Billing Unit Quantity
More often than not, a team will input the correct number of billing units into their practice management system, but the payer may pay at only one unit, leading to significant loss in revenue over time.
This problem occurs because different drugs use the same J code (e.g., J3499) even though practices must use custom codes in their own systems to differentiate between them. Even when those drugs have a specified correct number of units, payers don’t always read the manual narrative and simply pay at one unit.
Unfortunately, the only recourse and action is AFTER you’ve been underpaid, which makes things more challenging. But it’s worthwhile for a practice to pursue and validate after the fact.
6. Watch for the Release of a Permanent J Code
Unlisted J codes are a temporary problem, but they can haunt a practice for longer than they should. A practice needs to watch for the release of a permanent J code. As soon as it arrives, make the switch. Update your inventory management system, practice management system, and pathway solution – anywhere the J code for that pharmaceutical is referenced. Not updating all your systems could lead to dollars lost.
Patience and persistence are a virtue here as it can take anywhere from 6-12 months for a permanent J code to be released.
The compound effect that unlisted J codes can have – from usage to billing – can be immense. However, this process can be managed in a more efficient and effective manner if your team has good visibility through reporting and analytics.