Esketamine (SPRAVATO®) offers a promising solution for treatment-resistant depression and acute suicidality, bringing hope to countless patients.

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By incorporating SPRAVATO® as a service line in your practice, you can create a win/win situation that benefits both your bottom line and your patients' well-being.

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However, integrating this treatment into your practice can pose unique challenges, such as navigating the REMS program and handling complex billing procedures.

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In this comprehensive guide, we'll equip you with the essential information to successfully integrate esketamine (SPRAVATO®) into your practice:

• What is SPRAVATO® (esketamine)?

• What is the typical treatment protocol for SPRAVATO?

• What are the Potential Side Effects of SPRAVATO®?

• What is the SPRAVATO® REMS program?

• How can you set up a comfortable treatment space?

• How can you streamline REMS administration and protect yourself?

• How do you navigate reimbursement challenges?

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Prefer audio? You can listen to Carlene MacMillan, M.D., and billing expert, Brittainy Wagner, LPC, here:
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What is SPRAVATO® (esketamine)?

SPRAVATO® is an FDA-approved nasal spray that contains esketamine, a rapid-acting and powerful antidepressant. It is used to treat treatment-resistant depression and acute suicidality in adults. By incorporating SPRAVATO® into your practice, you can provide a life-saving treatment option for patients who have not responded to other antidepressants.

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Which patients are eligible for SPRAVATO®?

Before offering SPRAVATO® in your practice, it's essential to understand its indications and patient eligibility criteria. SPRAVATO® is designed for patients with treatment-resistant depression or acute suicidality who have not responded adequately to at least two different antidepressants. Patients are also expected to remain on an oral antidepressant during the course of their treatment, as was the case in the clinical trials that led to FDA approval.

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What is the treatment and monitoring protocol for SPRAVATO®?

The typical treatment protocol for esketamine involves an initial induction phase of twice-weekly sessions for four weeks, followed by a maintenance phase with sessions every two to four weeks. Patients receiving SPRAVATO® must be monitored for at least two hours after administration, during which they should not drive or operate heavy machinery and must remain in the office with a physician or nurse practitioner on site who is qualified to intervene in the case of an emergency.

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What are the potential side effects of SPRAVATO®?

Common side effects of esketamine treatment include dizziness, nausea, anxiety, and increased blood pressure. As with ketamine, there can also be dissociation although, this is typically fairly mild with intranasal esketamine compared with IV or IM ketamine. As a clinician, it's crucial to monitor patients for adverse reactions and manage side effects appropriately.

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What is the SPRAVATO® REMS program?

The Risk Evaluation and Mitigation Strategy (REMS) program is mandated by the FDA to ensure the safe use of esketamine (SPRAVATO®) by minimizing the risk of serious adverse outcomes resulting from sedation, dissociation, and abuse potential.

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The REMS program can be time-consuming, requiring healthcare providers, patients, and pharmacies to enroll and comply with specific requirements to ensure the safe administration of the treatment. This includes submitting a form to the REMS program after each administration of esketamine.

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Now you’ve determined if a patient is a good fit for SPRAVATO®, and what hurdles exist. Next, let’s explore how to set up your treatment space.

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Setting up your esketamine/SPRAVATO® treatment space

Once you have enrolled your outpatient location to offer esketamine, you will also need to purchase a safe to store the esketamine and train staff in how to manage its inventory to comply with all DEA regulations.

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The next step is to set up the space to be comfortable and efficient. Creating a comfortable and welcoming environment is essential for providing effective esketamine treatment. Each option has its unique advantages and considerations, which we will delve into below.

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Private Room:

When privacy is a top priority for your patients, a private room can be the ideal choice. This setup:

• Provides patients with privacy and comfort
• Allows for greater personalization of the space
• Would entail the need for video monitoring if more than one patient is getting esketamine at the same time. A Video baby monitor or the use of Ipads with video conferencing can work well.

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Shared Room with Screen

For practices looking to maximize space and resources, a shared room with a screen may be the best solution. This option:

• Allows for multiple patients to be treated simultaneously without the need for additional monitoring audio/visual equipment

• Ensures patient privacy with a partition or screen

• Cost-effective for practices with limited space or resources

• Can accommodate group therapy sessions or peer support opportunities

• Adjustable layout for varying patient needs and preferences

• Enables efficient use of staff resources for patient monitoring

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Couch Setup

To create a more relaxed and home-like atmosphere, consider incorporating a couch setup in your treatment space.

• Many patients prefer a couch or recliner for comfort

• This setup provides a more relaxed atmosphere

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Additional Considerations

In addition to the primary setup options, there are several other factors to consider when creating the ideal esketamine treatment environment. These include:

• Soft lighting to create a calming environment

• Blankets, pillows, and other comforting items

• Sleep masks

• Adult coloring books, encouraging the use of a journal or other activities. Note that Janssen provides a patient booklet that contains some activities.

• A designated area for monitoring patients during treatment

• Playlists designed for ketamine treatment or patients bringing their own music

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Selecting the right esketamine treatment setup is crucial for providing a comfortable and effective environment for your patients. Evaluate your practice's unique needs and resources to determine the best configuration for your space, keeping patient privacy, comfort, and preferences in mind.

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Next, we'll cover Billing considerations.

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Billing and reimbursement for esketamine (SPRAVATO®) treatment

Understanding the cost and reimbursement process is crucial for the successful integration of esketamine treatment into your practice. Here are some key points to consider:

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What’s the cost of esketamine/SPRAVATO®?

• The cost of esketamine (SPRAVATO®) varies based on several factors, including the supplier and quantity purchased. On average, the cost ranges from $700 to $900 per 84mg dosage.

• Research different suppliers and negotiate prices to secure the most cost-effective option for your practice. Some suppliers may offer discounts or incentives, such as volume-based pricing, when purchasing larger quantities.

• Some suppliers offer payment terms that allow healthcare providers to pay for the medication within a specified period, such as 90 days, providing flexibility in managing cash flow.

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SPRAVATO® billing codes

Appropriate billing codes specific to SPRAVATO® (esketamine) treatment, not intravenous (IV) or intramuscular (IM) ketamine treatments, ensure proper reimbursement and avoid claim denials.

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The method of billing depends on whether you're using the "buy and bill" approach, where you obtain the medication from a distributor, or prescribing it through a REMS-Certified specialty pharmacy and using the patient’s pharmacy benefit. The choice of method may depend on the patient's insurance and the nature of the payer (commercial or Medicare/Medicaid).

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Buy and bill

"Buy and bill" involves healthcare providers purchasing the medication directly from a distributor, then billing the medication's cost and its administration to third-party payers for reimbursement. In this scenario, providers also manage the drug inventory, collect copayments or coinsurance from the patients, prescribe, and administer the medication.

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For SPRAVATO®, "buy and bill" often involves additional costs and restrictions. There's typically an administration fee separate from the drug's cost. Providers may use the S code or the G code for reimbursement, but if the purchase cost exceeds the insurance reimbursement, they might opt for prescribing Spravato from a pharmacy.

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For Buy And bill:

• For Medicare and some commercial payers, use a special combination G code (G2082 for 56mg and G2083 for 84mg) that includes the cost of the drug and the visit itself. No additional codes for evaluation and monitoring are necessary.

• For most commercial payers, include Drug HCPCS coding (56 or 84 units of S0013) along with the relevant evaluation and monitoring codes.

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If using a patient’s pharmacy benefit and a REMS-certified specialty pharmacy:

• Use Evaluation and Management (E/M) codes based on time spent (99212-99215 plus codes for additional physician or staff time). For Physician monitoring, use 99215 + 99417 x 3 or 4 units (each unit represents 15 minutes). For Physician plus staff monitoring, use 99212-99215 (depending on physician involvement) + 99415 + 99416 x appropriate units for time spent.

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Medicaid reimbursement for SPRAVATO®

• Medicaid reimbursement rates for SPRAVATO® treatment vary by provider type and geographic location. Check your state Medicaid program's reimbursement rates and coverage policies.

• Typically, Master's level providers like nurse practitioners and physician assistants receive approximately 85% of the reimbursement rate compared to physicians.

• Ensure the patient's Medicaid eligibility and verify that SPRAVATO® treatment is covered under their specific plan to avoid unexpected costs.

• For "dual-eligible" patients (those with Medicare and Medicaid), and for Medicaid patients in general, payers require an 11-digit NDC code and units on the claim to identify the drug: N450458-0028-02 UN2 units for 56mg, and N450458-0028-03 UN3 units for 84mg.

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Takeaway: Ultimately, the decision between "buy and bill" or using pharmacy benefits depends on the provider's fee schedule with the insurance company and which option is more financially advantageous.

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Financial assistance with Jansen Carepath

If SPRAVATO® isn't covered under the patient's insurance pharmacy benefits, Janssen, the manufacturer, offers discounts or a savings plan to assist with the cost.

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Navigating challenges in billing and reimbursement for SPRAVATO

Successfully navigating billing and reimbursement for esketamine treatment requires a strategic approach to payer negotiations and being aware of potential challenges:

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Payer Negotiations

• Review and negotiate payer contracts to secure favorable reimbursement rates for SPRAVATO® treatment.

• Pay special attention to the reimbursement rates for codes like 99417 (Prolonged office or outpatient evaluation and management service by a physician), 99415 and 99416 (prolonged clinical staff services) which may be used for extended monitoring during treatment.

• Build strong relationships with specific payers to achieve better contract terms and facilitate negotiations.  Incorporating measurement-based care to demonstrate clear outcomes and tracking utilization of higher levels of care such as avoiding visits to ERs and inpatient units can help secure more favorable contracts.

• Collaborate with payer representatives to address any concerns or questions they may have about esketamine treatment and its clinical benefits.

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Geographic Variability

• Reimbursement rates for esketamine treatment can vary significantly between geographic locations.

• Understand the rates specific to your practice location to ensure appropriate billing.

• Consider partnering with other providers or join provider networks in your area (known as independent practice associations or IPAs) to negotiate better rates with payers. This collaborative approach can enhance your bargaining power and improve reimbursement outcomes.

• Due to new regulations around price transparency, more information about claims payments and reimbursement should be available to the public. Keep in mind, however, that your contract with a given payer typically includes language around not sharing specific rates with your colleagues so please review these contracts and consult with an attorney if you have questions about what you are allowed to share.

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Common Payer Issues

• Be prepared for challenges such as under-reimbursement, where payers reimburse at lower rates than expected, or misapplied payments, where payments are applied to the wrong claim or service.

• Payers may show inconsistency in coverage for add-on codes, making it challenging to predict reimbursement for certain services provided alongside esketamine treatment.

• If you are not in-network with a payer but want to be considered in-network for a specific patient who is interested in esketamine, you can consider obtaining a single-case agreement (also known as an out-of-network exception. Obtaining single-case agreements with certain payers can be difficult, especially if the payer does not have an established contract for esketamine treatment. Sometimes this involves the patient taking the lead and doing most of the heavy administrative lifting. Other times it involves more practice involvement. If a payer grants a single-case agreement, be sure to include the authorization number on claims and track how many uses it allows and when it expires.

• Integrating SPRAVATO® into your practice may seem tricky due to challenges like the REMS and complex billing procedures. The good news? Osmind EHR makes offering SPRAVATO® simple. With custom patient intake forms and automated REMS submissions, streamlining your workflow and enhancing patient satisfaction just got easier. We also have an active Practice Community where clinicians and administrative staff share tips around how to best offer a thriving esketamine service line at your practice.

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Read how to automate cumbersome documentation with Osmind’s SPRAVATO REMS Automated Patient Monitoring Form.

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Conclusion

Esketamine (SPRAVATO®) is a breakthrough treatment option for patients with treatment-resistant depression and acute suicidality.

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As a private practice psychiatrist, following this guide enables you to effectively integrate esketamine treatment into your practice, offering outpatient life-saving care to those who may struggle to afford other options while maintaining profitability—a win-win for both you and your patients.

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Osmind EHR's seamless integration with the SPRAVATO® REMS program streamlines the process. You save hours of administrative burden, empowering you to concentrate on delivering the highest quality of care to your patients.

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Learn how Osmind makes offering SPRAVATO® simple and profitable.