Buy-and-Bill

Buy-and-bill is when a practice purchases a drug, administers it, then bills the payer for it — a high-dollar, high-risk model where a single denial can mean thousands in unrecovered acquisition cost.

Buy-and-bill is the model where a practice buys a drug directly, stocks it, administers it to the patient in office, and then bills the payer for both the drug and its administration. It's common in specialties that give provider-administered drugs — infusions, injectables, oncology, rheumatology, ophthalmology — and it puts the practice's own money at risk, because you've paid the acquisition cost up front before the payer pays you back. That's what makes buy-and-bill denials so painful: a single denied high-cost drug claim isn't a small write-off, it's thousands of dollars of inventory you already bought and can't recover. Denials here cluster around prior authorization (the drug needed auth that wasn't obtained or linked), medical necessity, units and MUE limits, the wrong J-code or NDC, and site-of-service policies pushing administration elsewhere. Because the dollars per claim are so large, buy-and-bill is exactly where unrecovered denials do the most damage to a practice's margin — and exactly where working the appeal is most worth the effort. Underpayments matter here too: a drug reimbursed below acquisition cost, or an administration code bundled away, turns a treatment into a loss. Reconciling every high-cost drug claim against expected reimbursement is essential in this model.

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