If your home infusion business makes electronic transactions—such as billing and verifying eligibility—get ready. The Health Care Insurance Portability and Accountability Act (HIPAA) will mean changes in the industry, says Lorrie Kline Kaplan, executive director of the National Home Infusion Association (NHIA), Alexandria, Va. “The aspect of HIPAA that most concerns the home infusion industry is transaction and coding,” she says. “The home infusion industry is mostly managed care, and each managed care program has its own set of billing codes. ... Under HIPAA, we can’t do that.”

Effective April 14, 2001, HIPAA creates a catch-22 for home infusion—standard billing codes are required, but there are no standard codes for many of the services. More than 70% of home infusion patients are enrolled in managed care programs, each with a different set of billing codes. Although Kaplan says that HIPAA will eventually streamline paperwork and speed reimbursements, the lack of a standard coding system poses an obstacle for the industry.

“We need a system based on service codes, not just product,” says Ken Speidel, NHIA board president, executive director of Ritzman Infusion Services of Ohio, and vice president of specialty pharmacy services for Ritzman Pharmaceuticals Inc, Akron, Ohio. “We need a way to be paid for our services. These homegrown codes do not mean anything to anybody else’s computer system, so to collect any kind of data, someone needs to spend a lot of time.”

Coding and reimbursement problems led a group of infusion providers to form NHIA in 1991. Today, the association provides its 1,000 members with clinical and management information and serves as a legislative advocate for the $4 to $5 billion industry.

With a four-person staff, the association relies on committee members throughout the country to do much of the nuts-and-bolts work through monthly teleconferences. The Home Infusion EDI Coalition Committee (HIEC), for example, has developed a complete set of codes for the industry, and is working to have the codes accepted by the Centers for Medicare and Medicaid Services, formerly the Health Care Financing Administration.

“Our goal is to develop a standardized coding system that works for everyone,” Kaplan says. “We are not opposed to working with another coding system, but it has to be comprehensive enough to cover all of our functions.”

NHIA focuses mainly on the day-to-day business concerns of home infusion service providers. Kaplan estimates that there are between 4,000 and 5,000 sites of service in the United States, including national companies, hospital-based services, and regional companies. “Our job as an association is to convey what our people do,” Kaplan says. “There is a misconception that it is just a nursing visit.”

NHIA members would like to see Medicare and Medicaid implement the managed care reimbursement model—which usually covers supplies, medications, and a per diem rate for each day a patient is under a company’s care. According to Kaplan, this is a less expensive alternative to hospital care, which can cost up to one third more than home infusion therapy.

To facilitate this reimbursement model, NHIA officially defined per diem as “each day that a given patient is provided access to a prescribed therapy, beginning with the day the therapy is initiated and ending the day the therapy is discontinued.” Under this definition, a company’s service is compensated even if a patient does not receive an infusion product on a given day.

“If a patient is under our care, we need to be paid for that service,” Kaplan says. “Per diem is one of the most commonly used terms in home infusion. Defining it is another step to standardization of the industry.”

NHIA also offers providers an opportunity to measure their business outcomes against others in the industry. In a cooperative effort with a manufacturer and the University of Texas College of Pharmacy in Austin, an NHIA committee developed the Inter-Company Operational Benchmarking Project in 1998.

Participants submit data each month on five operational indicators—cost of goods sold, inventory value, net revenue, net receivables, and core pharmacy payroll. All the information is confidential and the program is free to members, who receive a quarterly report. Kaplan says that 60 to 100 sites participate.

Programs like these keep rural members, such as Debbi Naccarto, pharmacist and owner of At Home Solutions specialty pharmacies in Bozeman, Billings, and Kalispell, Mont, abreast of industry trends. “[In Bozeman] there are few opportunities for continuing education and little contact with other people in the field,” she says. “NHIA keeps me in touch.”

Creating a network of individual providers is essential to NHIA’s leverage in Washington, DC. With health care reforms such as HIPAA on the horizon, Kaplan sees hope for change in the home infusion industry. “We see HIPAA as a way to get standardization in billing and coding,” she says. “This will push the industry ahead light years.”

Lyn Kidder is a contributing writer for Dealer/Provider.