Infusion therapy plays a crucial role in patient care, with multiple delivery models designed to accommodate different clinical and financial needs. Each model has distinct operational, billing and reimbursement structures that influence how care is provided and paid for. Understanding these differences is essential for providers looking to navigate the complexities of the infusion landscape successfully.
Here’s a closer look at the three major infusion delivery models: Ambulatory Infusion Site (AIS), Ambulatory Infusion Center (AIC), and Home Infusion Pharmacy (HIP/HIT).
Ambulatory Infusion Site (AIS) – Pharmacy-Based Infusion Suite
An Ambulatory Infusion Site (AIS) is a dedicated infusion space within a pharmacy where patients receive medication under the supervision of a registered nurse. This setting is designed for individuals who require professional assistance with their infusion but do not qualify for home nursing services. Unlike hospital-based infusion settings, an AIS provides a more cost-effective and accessible option for patients who need ongoing infusion treatments without the complexity of in-home care.
Billing and reimbursement for AIS can vary significantly. Medicare does not cover services provided in an AIS, which means providers must rely on commercial insurance payers. Typically, commercial insurance reimburses for drug costs, per diem fees, and nursing services, making it a viable option for many pharmacies. Additionally, a physician is not required on-site, which allows for operational flexibility. Pharmacies bill private insurers for both medications and infusion services, avoiding the additional regulatory requirements seen in more clinical settings like an AIC.
Ambulatory Infusion Center (AIC) – Standalone Infusion Clinics
An Ambulatory Infusion Center (AIC) is an independent clinic where patients receive infusion therapy prescribed by external physicians. Unlike AIS, these centers focus exclusively on administration rather than prescription, offering a structured and supervised care setting that operates separately from a pharmacy. AICs are particularly beneficial for patients with chronic conditions requiring regular infusions but who do not require hospitalization.
From a reimbursement perspective, Medicare coverage is available for AICs; however, they must adhere to strict Medicare supervision rules, which require a physician, nurse practitioner, or physician assistant to be on-site during treatments. Commercial insurance covers medications, administration fees, and evaluation and management (E/M) services, ensuring a more comprehensive reimbursement structure. Physician oversight is mandatory, which affects staffing and operational costs but also provides a higher level of clinical care. AICs typically operate as provider-based clinics, with the referring physician purchasing and billing for medications, which differentiates them from both AIS and home infusion models.
Home Infusion Pharmacy – Bringing Infusion to the Patient
A Home Infusion Pharmacy is a closed-door pharmacy that prepares and dispenses infusion medications for delivery to patients’ homes. This model supports both self-administered infusions and in-home nursing-assisted treatments, offering flexibility for patients who prefer or require treatment outside of a clinical setting. Home infusion is particularly advantageous for individuals with mobility issues or those who need long-term infusion therapy in a comfortable environment.
The reimbursement landscape for HIP varies depending on the payer. Medicare coverage is limited, as only specific infusion services qualify under Medicare Part B. However, commercial insurance generally reimburses drug costs, per diem charges and in-home nursing services, making it an essential option for many patients. Unlike AICs, HIPs do not require an on-site physician, though home health nurses often provide patient support. The billing structure enables pharmacies to bill for both medications and nursing services, making this model highly adaptable and patient centered.
How Prochant Supports Coverage for Infusion Centers
- Eligibility & Verification: Prochant’s EVPA (Eligibility, Verification and Prior Authorization) service ensures that insurance benefits are verified upfront, preventing delays in reimbursement.
- Prior Authorization Management: Their team secures timely approvals from payors, reducing the risk of claim denials due to missing authorizations.
- Claims Submission & Tracking: Prochant’s experts handle accurate coding and billing, minimizing errors that can lead to claim rejections or underpayments.
- Denial Prevention & Appeals: With AI-driven denial prediction and proactive follow-ups, Prochant reduces coverage-related denials and accelerates appeals when necessary.
- Analytics & Insights: Our Prochant Pulse platform provides real-time visibility into insurance coverage trends, reimbursement rates and payor performance, helping infusion centers optimize financial outcomes.
By outsourcing RCM to Prochant, infusion centers can focus on delivering patient care while ensuring that services are properly covered and reimbursed.
Ready to streamline your infusion billing and claims management? Contact Prochant today!
