Demystifying the Buy-and-Bill Model: What Specialty Practices Need to Know in 2026

Buy-and-bill remains one of the most effective models for delivering physician-administered biologics in-office, but it is also one of the most misunderstood.

For specialty practices in rheumatology, gastroenterology, neurology, and pulmonology, buy-and-bill can be the difference between delayed starts and predictable access.

In 2026, the model remains highly viable. However, rising drug acquisition costs, reimbursement variability, and heightened compliance scrutiny have made buy-and-bill more operationally demanding than ever. With the right structure, practices can run buy-and-bill safely, compliantly, and sustainably—without overwhelming internal teams.

At Altus Biologics, we help specialty practices operate buy-and-bill programs with tight controls, payer-aware workflows, clean documentation, and streamlined billing support so patients can access the therapies they rely on.

What to Know

• Buy-and-bill means the practice purchases the biologic, administers it in-office, then bills the payer under the medical benefit.
• Financial risk is real, but manageable with authorization discipline, inventory controls, and claims accuracy.
• Medicare Part B reimbursement is generally ASP-based, while commercial reimbursement varies by contract.
• Most buy-and-bill friction comes from avoidable gaps, including incorrect units, missing documentation, misaligned payer requirements, or delayed claim submission.
• A well-run buy-and-bill strategy can reduce delays, improve continuity, and support access for biologic-dependent patients.

What the Buy-and-Bill Model Means and Why It Still Matters in 2026

Buy-and-bill is a provider-administered distribution and reimbursement model in which a specialty practice purchases a medication upfront, administers it in-office, and bills for both the drug and its administration after the payer processes the claim.

Unlike the specialty pharmacy model, where medication is dispensed to the patient (or shipped to the clinic) and billed under the pharmacy benefit, buy-and-bill allows practices to maintain greater control over:

• Timing and scheduling
• Dose accuracy
• Continuity and monitoring
• Patient experience during infusion/injection visits

When executed correctly, buy-and-bill can also help prevent treatment disruption caused by pharmacy routing issues or shipping delays.

Buy-and-Bill Reimbursement Mechanics, Working Capital, and Risk Mitigation

Understanding the model’s financial mechanics helps reduce anxiety and prevent avoidable losses.

Step 1: Practice purchase (upfront cost)

The practice orders the biologic and pays the distributor or manufacturer. Working capital impact begins here because the drug may be purchased days or weeks before reimbursement.

Step 2: Care delivery and required documentation

To protect reimbursement, documentation must support medical necessity and payer requirements, including:

• Diagnosis and indication
• Prior authorization details
• Dose, wastage (if applicable), and administration notes
• NDC and lot tracking when required

Step 3: Claim submission: Clean billing and reimbursement accuracy

Claims must align with payer requirements, including correct:

• HCPCS/J-codes, units, and modifiers
• Date of service
• Linkage to authorization/reference numbers

Step 4: Payer reimbursement (cash inflow)

After adjudication, the payer reimburses the practice for the drug and administration services. The margin between reimbursement and acquisition cost is not guaranteed. It depends on payer rates, claims accuracy, and the speed and cleanliness of submission and payment.

Buy-and-Bill Misconceptions: Common Myths and Real-World Risks

Misconception #1: “Buy-and-bill only works if you game reimbursement.”

Reality: Sustainable buy-and-bill performance comes from operational excellence that includes payer-aware workflows, clean documentation, and billing accuracy.

Misconception #2: “Cash flow problems are unavoidable.”

Reality: Cash flow can be stabilized through predictable purchasing, inventory discipline, timely clean claims, and denial prevention processes.

Misconception #3: “Compliance is mostly about billing codes.”

Reality: Compliance spans documentation, medical necessity, storage requirements, inventory controls, payer rules, and audit readiness. Strong internal controls reduce risk and protect long-term viability.

Buy-and-Bill in 2026: Rising Complexity, Higher Scrutiny, and Continued Value

In 2026, buy-and-bill is operating in a more complex reimbursement environment. Costs are higher, payer policies are more granular, and post-pay audit activity continues to rise. The question is not whether buy-and-bill still works—it does—but whether workflows are engineered to protect cash flow, reduce denials, and maintain compliance at scale.

When optimized, buy-and-bill can expand access for patients who rely on biologics by supporting faster starts after approval, reducing disruptions, and improving continuity of care.

How Altus Biologics Supports Safe, Compliant Buy-and-Bill Operations

Altus Biologics helps specialty practices reduce financial risk and administrative overload through structured, compliant buy-and-bill operations. Altus support can include:

• Buy-and-bill program design and optimization
• Inventory and process controls
• Payer-aware documentation workflows
• Claims accuracy and reimbursement optimization
• Operational systems that reduce denials and rework

Our goal is simple: help practices deliver biologics efficiently, compliantly, and with less internal strain so that patients can stay on therapy without disruption.

FAQ: Buy-and-Bill in Specialty Practices

What is the biggest financial risk in buy-and-bill?

Working capital lag and denial risk. Buy-and-bill performs best when claims are clean, submitted quickly, and supported by precise authorization and documentation.

How can practices avoid losses on high-cost biologics?

Through payer verification before acquisition, correct coding/units, denial prevention checklists, inventory discipline, and payer-aware billing workflows.

Is buy-and-bill better than specialty pharmacy?

Both models have advantages, but for infusion-based biologics, buy-and-bill often improves continuity, scheduling control, patient experience, and speed of care delivery.

How does Altus Biologics reduce administrative load?

By reducing workflow chaos through more standardized processes, cleaner billing, compliance controls, and fewer staff hours spent on rework.