Infusion provider wins claims appeal

Tuesday, November 23, 2010

MERIDIAN, Miss. - A home infusion provider won a victory of sorts when a federal court ruled in September that a Medicare contractor must pay for certain services that it had refused to cover.

"It's nice to hear a federal court say we were right," said David Franklin, CEO of Vital Care, a franchise with nearly 100 locations, mostly in the Southeast.

The issue: Dallas-based Trailblazer Health Enterprises, which has Medicare contracts in Texas, Virginia and Oklahoma, had stated that Medicare Part B does not cover infusion drugs administered through an implanted infusion pump. It stated that only drugs administered by a physician were covered.

Vital Care appealed all the way to the Administrative Law Judge and enlisted the help of Sen. James Inhofe, R-Okla.

The September ruling was in Vital Care's favor, but the provider has yet to see any payments on the  "thousands" of claims that had been denied or that it had held back. The claims represent about 400 Vital Care patients and go back to August 2009.

"Sen. Inhofe has been sending letters to CMS and to Trailblazer, but they've been stonewalling," said Franklin. "We are holding claims and waiting for them to say, 'OK, we'll pay for them.'"

Meanwhile, Vital Care has continued to provide the needed drugs to its patients, many of whom are cancer patients receiving chemotherapy. 

"A lot of these patients are immuno-compromised," he said. "The worst place to send them would be to the hospital, where they can get hospital-acquired infections and die. I don't think it's an overstatement to say we were fighting for their lives."

At the end of the day, the ruling may come too late for some of Vital Care's franchises.

"I got notice one of our locations may close," said Franklin. "They are out of money."