Buy and Bill and assignment of benefits are the two primary reimbursement models for Spravato administration under the medical benefit.
Buy and Bill is a provider-directed model for Spravato procurement that requires clinics to purchase and inventory the medication before seeking payer reimbursement.
Assignment of benefits is a pharmacy-directed Spravato fulfillment approach that shifts drug billing and financial risk to a REMS-certified specialty pharmacy.
Mental health practices choose between these Spravato procurement models based on cash flow capacity, administrative infrastructure, and reimbursement strategy.
Selecting the correct Spravato reimbursement method improves treatment access, stabilizes clinic operations, and aligns payer billing with practice capabilities.
What Is Buy and Bill in Spravato?
Buy and Bill means your practice purchases Spravato directly from an authorized specialty distributor. You acquire the product, administer it to your patient, and then submit a claim to the insurance company for reimbursement.
This method requires upfront capital. You pay for the medication before receiving payment from the insurer. Most practices use Buy and Bill when patients have coverage under the medical benefit.
The process follows this sequence:
- Order Spravato from a specialty distributor
- Receive and store the medication in your office
- Administer Spravato to your patient
- Submit a claim for both the drug and the administration service
- Receive reimbursement from the insurance company
Your practice assumes financial risk during the time between purchase and reimbursement. This period can range from 30 to 90 days, depending on payer processing times.
Advantages of Spravato Buy & Bill
- Control over administration: Providers manage dosing, scheduling, and monitoring directly.
- Immediate treatment availability: Patients can receive Spravato during their visit without waiting for insurance approvals.
- Higher reimbursement rates: Clinics may receive higher payments compared to patient-directed models.
Challenges of Spravato Buy & Bill
- Upfront financial burden: Purchasing Spravato requires a significant initial investment.
- Inventory management: Providers must handle storage, track expiration dates, and maintain compliance with handling rules.
- Complex billing: Submitting claims requires knowledge of Spravato billing & coding, payer rules, and potential claim denials.
What Is Assignment of Benefits in Spravato?
Assignment of benefits takes a different approach. A REMS-certified specialty pharmacy delivers Spravato to your office. You do not purchase the medication. Instead, the pharmacy bills the patient’s insurance directly for the drug.
You only bill for the administration and monitoring services you provide. The pharmacy handles drug procurement, storage before delivery, and billing for the medication itself.
This method requires an agreement between your practice, the patient, and the pharmacy. The agreement allows the patient’s insurance to pay the pharmacy directly while you bill separately for services.
Assignment of benefits works when patients have coverage under the medical benefit, but your practice prefers not to purchase the drug directly.
Advantages of Spravato AOB
- Reduced financial risk for patients: Patients avoid paying high upfront costs.
- Simplified patient experience: Less paperwork and direct billing to insurance.
- Faster cash flow for providers in some cases: Payment comes directly from the insurance company.
Challenges of Spravato AOB
- Requires patient consent and understanding: Providers must educate patients on signing and authorizing AOB forms.
- Potential delays: If insurance denies or delays approval, treatment may be postponed.
- Less control over reimbursement rates: Providers depend on payer policies for payment amounts.
Differences Between Buy and Bill & AOB
The financial responsibility differs significantly. With Buy and Bill, you own the medication and carry the inventory risk. With assignment of benefits, the pharmacy owns the medication until administration.
Cash flow impact varies between methods. Buy and Bill requires substantial upfront investment. You must maintain working capital to purchase medications before receiving payment. Assignment of benefits eliminates this requirement. You only bill for services, which typically have lower dollar amounts than drug costs.
Administrative processes differ. Buy and Bill requires you to manage:
- Ordering from specialty distributors
- Inventory management
- Storage compliance
- Drug procurement documentation
- Both drug and service billing
Assignment of benefits requires you to:
- Coordinate with specialty pharmacies
- Establish AOB agreements
- Manage service billing only
- Track medication deliveries
Reimbursement coding changes based on your method. Buy and Bill claims include both drug codes and service codes. Assignment of benefits claims only include service codes.
| Feature | Buy and Bill | Assignment of Benefits (AOB) |
| Ownership / Risk | Clinic owns medication → carries inventory risk | Pharmacy owns medication until administration |
| Cash Flow | High upfront cost → must maintain working capital | No upfront cost → bill only for services |
| Administration | – Order from specialty distributors- Manage inventory- Ensure storage compliance- Maintain procurement documentation- Bill for drug + services | – Coordinate with specialty pharmacies- Set up AOB agreements- Bill for services only- Track deliveries |
| Reimbursement Coding | Claims include drug + service codes | Claims include service codes only |
Coding for Buy and Bill
When you use Buy and Bill, your coding depends on payer requirements. Medicare and some commercial payers require bundled G codes that include both drug and service:
- For doses of 56 mg or less: G2082 covers the drug, evaluation and management, and two hours of post-administration observation.
- For doses greater than 56 mg: G2083 covers the drug, evaluation and management, and two hours of post-administration observation.
Commercial payers may accept separate billing. You report:
- S0013 for esketamine nasal spray (1 mg per unit)
- E/M codes (99202-99205 for new patients, 99212-99215 for established patients)
- Prolonged service codes when applicable (99417, G2212)
- Prolonged clinical staff service codes when applicable (99415, 99416)
Each 28 mg spray device equals 28 units of S0013. A 56 mg dose requires reporting 56 units. An 84 mg dose requires reporting 84 units.
You must verify coding requirements with each payer before submitting claims. Some payers accept G codes. Others require separate drug and service codes.
Coding for Assignment of Benefits
Assignment of benefits simplifies your coding. You do not bill for the medication. Your claims only include service codes.
Report appropriate E/M codes based on:
- Whether the patient is new or established
- Total time spent on the encounter date
- Level of medical decision making
For established patients, codes range from 99212 (10 minutes minimum) to 99215 (40 minutes minimum). For new patients, codes range from 99202 (15 minutes minimum) to 99205 (60 minutes minimum).
Spravato requires at least two hours of post-administration monitoring. This time often exceeds standard E/M code time ranges. You can report prolonged service codes when your time exceeds the maximum for your selected E/M code.
For physician time beyond the E/M code:
- Report 99417 (commercial payers) or G2212 (Medicare) for each additional 15 minutes
- Start counting after the maximum time in your E/M code range
For clinical staff time with physician supervision:
- Report 99415 for the first hour beyond the E/M service
- Report 99416 for each additional 30 minutes
You cannot report both physician prolonged codes and clinical staff prolonged codes on the same date of service.
When to Choose Buy and Bill
Select Buy and Bill when:
- Your practice has sufficient working capital
- You want direct control over medication inventory
- Your patient volume justifies inventory investment
- You prefer single-source reimbursement
- Your practice management system handles complex drug billing efficiently
Buy and Bill works well for established practices with strong cash flow, especially when handled by an experienced Spravato billing service provider. It gives you control over the entire treatment process from procurement to reimbursement.
This method suits practices treating high volumes of Spravato patients. You can maintain appropriate inventory levels and reduce delivery coordination requirements.
When to Choose Assignment of Benefits
Choose assignment of benefits when:
- Your practice lacks capital for upfront drug purchases
- You prefer to minimize inventory risk
- You want simplified billing processes
- Your patient volume is lower
- You want to reduce administrative burden
Assignment of benefits suits smaller practices or those starting Spravato treatments. You avoid the financial risk of purchasing expensive medications before receiving payment.
This method works for practices with limited storage space. You receive medications only when needed for scheduled patient visits.
Implementation Steps for Buy and Bill
First, verify your patient’s insurance covers Spravato under the medical benefit. Contact the payer to confirm coverage and obtain prior authorization if required.
Second, establish accounts with authorized specialty distributors like Besse Medical, Cardinal Health Specialty Distribution, and CuraScript Specialty Distribution.
Third, order Spravato in appropriate quantities. Consider your patient schedule and storage capacity. Each dose kit contains either two devices (56 mg total) or three devices (84 mg total).
Fourth, maintain proper storage conditions. Follow all REMS requirements for medication handling and security.
Fifth, document all services thoroughly. Record administration time, monitoring activities, and any adverse events. This documentation supports your billing and protects against audits.
Sixth, submit claims promptly. Use appropriate codes based on payer requirements. Include all necessary documentation such as NDC codes, diagnosis codes, and service details.
Implementation Steps for Assignment of Benefits
First, identify REMS-certified specialty pharmacies that accept assignment of benefits arrangements. Enhanced Service Pharmacy Network members include Accredo Health Group, AllianceRx, CVS Specialty, and Genoa Healthcare.
Second, establish an AOB agreement. This legal document allows the pharmacy to bill the patient’s insurance directly while you bill for services.
Third, coordinate delivery schedules. Work with the pharmacy to ensure medication arrives before scheduled patient appointments.
Fourth, verify insurance coverage for your services. Confirm the payer reimburses administration and monitoring codes separately from drug costs.
Fifth, document your services completely. Track time spent on evaluation, management, administration supervision, and post-dose monitoring.
Sixth, submit service claims after each treatment session. Include appropriate E/M codes and prolonged service codes based on actual time spent.
Financial Considerations
Buy and Bill requires significant upfront investment. A single 84 mg dose kit can cost several hundred dollars. Practices treating multiple patients weekly need substantial working capital.
Calculate your expected reimbursement timeline. Most payers process claims within 30 to 45 days. Factor this delay into your cash flow projections.
Assignment of benefits eliminates drug procurement costs. You only need capital for operational expenses related to service provision. This reduces financial risk substantially.
Consider reimbursement rates for both methods. Some payers reimburse bundled G codes at rates that differ from separate drug and service billing. Compare expected reimbursement amounts before choosing your method.
Administrative Requirements
Buy and Bill & AOB both methods require REMS certification. Your healthcare setting must enroll in the Spravato REMS program before receiving or administering any medication.
Buy and Bill adds inventory management responsibilities. You must track medication receipt, storage, usage, and waste. Maintain detailed records for auditing and compliance purposes.
Assignment of benefits requires coordination with external pharmacies. Establish clear communication protocols for ordering, delivery confirmation, and issue resolution.
Both methods demand accurate documentation. Record all services provided, time spent, and clinical observations. This documentation supports billing and demonstrates medical necessity.
Payer Policy Variations
Different payers have different requirements. Some mandate specific procurement methods. Others allow you to choose based on your practice preferences.
Medicare typically requires G codes for Buy and Bill situations. Medicare Advantage plans may allow either method depending on benefit design.
Commercial payers vary widely. Some accept S codes for separate drug billing. Others prefer bundled G codes. Many allow either approach based on provider preference.
Always verify requirements with each payer before treating patients. Contact the payer’s provider services department to confirm coverage policies, required codes, and pre-authorization requirements.
Final Words
Your choice between Buy and Bill and assignment of benefits depends on multiple factors. Assess your practice’s financial capacity, administrative capabilities, and patient volume.
Practices with strong cash flow and high patient volumes often prefer Buy and Bill. This method gives complete control and potentially simpler workflows once established.
Smaller practices or those starting Spravato treatments often choose assignment of benefits. This approach lowers administrative complexity and financial risk.
You can also use both methods for different patients. Some payers require specific approaches. Maintaining capability for both options gives you maximum flexibility.
The right choice supports your practice operations while ensuring patients receive timely access to Spravato treatment. Consider your unique circumstances carefully before committing to either method.
