10/4/10. Risë Marie Cleland

Transcription

1 Risë Marie Cleland describe trends increasing the financial risk for practices & patients, understand how financial counseling minimizes this risk identify key tasks & Best Practices in financial counseling 1

2 Recent reports show that the cost of cancer care is increasing by >15% annually New cancer drugs can cost thousands of dollars per treatment 2006 survey found: 25% of patients with insurance reported using up all or most of their savings to pay for cancer care 33% of families reported having trouble paying their cancer bills Source: USA Today/Kaiser Family Foundation/Harvard School of Public Health National Survey of Households Affected by Cancer (conducted Aug 1-Sept 14, 2006) 5 Yrs. Ago Today 5 Yrs. In Future Source: National Analysts Worldwide

3 Premiums Deductibles Co-Insurance Out-of-Pocket Limits Prior-Authorizations Formularies According to a recent survey, in 2011: 63% of employers plan to increase employees share of premium costs, 46% plan to raise out-of-pocket maximums, 61% of employers will offer a high-deductible consumer directed health plan (CDHP) in % of employers will offer only CDHPs National Business Group on Health (NBGH) Survey 3

4 KJT Survey Sponsored by US Oncology 2008 Shrinking reimbursement for IV drugs has forced Practices to stop Administering them. Private practices are sending more pts. to hospital centers for IV Drugs. Changing economics of cancer care will require that pts travel further than today. Source: National Analysts Worldwide

5 Develop, apply & monitor policies for: Accuracy of Patient and Payer Demographics Patient Financial Counseling Compliance with Payer Coverage Policies Patient Assistance Payment Policies Collection Process 5

6 Financial Counselor (FC) duties may be divided among several staff members, this will be influenced by: Practice size, patient demographics, payer mix and practice policies regarding patient assistance FCs should have a thorough understanding of: The oncology practice & services provided Practice finance and collections Key elements of medical coverage & benefits Individual payer coverage rules The FC should also posses the following skills: Excellent communicator A good listener Analytical Detail oriented Ability to advocate on patient s behalf Unafraid to inquire about patient s finances Ability to ask for payments in a professional manner 6

7 Educate patients about their insurance benefits, copays, co-insurance amounts, and any insurance limitations Educate patients about practice financial policies: Expectations for co-pay, co-insurance collections Determine costs associated with treatment plans and identify areas of financial risk to the practice & patient Communicate findings to patient & patient care team Verify that treatment plans comply with payer medical policies Monitor patients insurance for changes in coverage and benefits Monitor changes in patients financial status Monitor patient balances to improve collections May also help patients obtain outside financial assistance : Through local, state or federal programs, drug assistance programs, local or national advocacy and non-profit organizations 7

8 Identification of Underinsured/Uninsured Patients Compliance with Payer Coverage Policies Discussion of Treatment Costs and Payment Expectations with Patients Improved Collections Uninsured/Underinsured 8

9 Will you treat underinsured and/or uninsured patients in your office - under what circumstances? Ability to pay at time of service? Availability of patient assistance for drugs and/ or copay assistance? Is there a financial liability limit that the practice is comfortable with? Use state & federal poverty guidelines to develop charity care guidelines Establish a practice policy for these circumstances Apply it Monitor it 9

10 Verify demographics Insurance benefits policy effective date Obtain any necessary referrals & prior-authorizations Identify patients with no insurance, poor insurance High deductible plans High co-payments High out of pocket limit Reduced coverage benefits Identify patients with no 2nd insurance And secondary policies that do not pick up all balances after primary Identify patients with special coverage issues Cobra Health Savings Accounts Medicaid Prior to treatment Financial Counselor should have a detailed treatment plan that includes: Diagnosis Chemotherapy drugs Dose Frequency Supportive care drugs Dose Frequency Labs and other necessary tests Follow-up visits 10

11 FCs will identify any coverage issues particular to the patient s specific treatment plan Drugs Co-payments Formularies, step-therapies Dosage limits Frequency limits Benefit limits lifetime, yearly, per-day limitations Pre-existing clauses Identify site of service restrictions Hospitals Labs Imaging Drugs (Specialty Pharmacies, Pharmacy Benefit Management programs) Prior authorization requirements Office visits Chemotherapy, supportive care drugs Labs, other tests 11

12 Private & Public Payers FCs must stay abreast of payer s medical policy coverage guidelines: Most major payers publish medical policies on their websites, Sign up for newsletters & alerts when available. Many private payers (including UnitedHealthcare) follow NCCN guidelines. 12

13 FDA indications package insert Compendia listing American Hospital Formulary Service-Drug Information (AHFS-DI) National Comprehensive Cancer Network (NCCN) Drugs and Biologics Compendium Thomson Micromedex DrugDex Clinical Pharmacology National Coverage Determination (NCD) Local Coverage Determination (LCD) FCs review treatment plan and reported diagnoses for compliance with payer s Medical Policy FDA indications Compendia listings FC reports potential medical necessity denials to physician Alternate treatment options may be explored at this point 13

14 Oncology practices and their patients need to know coverage benefits and limitations prior to the initiation of treatment The practice needs to know what services will be covered by the payer, and the patient s ability to pay their copays/ coinsurance, and The patient needs to understand treatment options and cost implications, an estimated cost of treatment (per cycle, regimen or expected overall treatment) 14

15 Cost transparency Allows patients to make financial decisions about their healthcare Allows practices to determine patient financial liability Some payers require physicians to provide patients with a written estimate of treatment costs ASCO has identified the discussion of cost of care as an important component of high quality care The Financial Counselor determines the estimated total cost of the patient s treatment and the expected patient costs based on the patient s treatment plan and insurance benefits The Financial Counselor provides the patient with: Expected out-of-pocket responsibility Clinic expectations for payment Available payment options such as credit card payments and automatic debits 15

16 Prior to treatment FC communicates the following to the health care team: Any potential coverage benefit issues for patient s treatment plan Any potential medical necessity concerns Any potential patient financial concerns Decision to proceed with treatment will be based on practices established policies including: Compliance with Payer Coverage Policies Patient Assistance Payment Policies and Patient s acknowledgement and acceptance of their financial liability and practice payment expectations 16

17 FC enrolls patient in prior-authorization and/or patient assistance programs If service is likely to be denied for medical necessity: FC obtains signed Advance Beneficiary Notice Begins process of gathering supporting literature Alerts applicable staff members to prepare for denial and appeal 17

18 All new patients meet the financial counselor as part of the intake process Include patient s family/caregiver All chemotherapy patients should meet with the counselor before starting a regimen All treatment plans should be reviewed and approved according to practice policy prior to initiation of treatment Re-verify insurance policies routinely Watch for changes in employment status or insurance coverage Review insurance benefits & patient financial responsibility when treatment plan changes Monitor co-payment collections Check appt. schedule in advance for patients with copayment balances Meet with patients with high unpaid balances 18

19 Collection of all co-payments & deductibles Verification of current insurance Before Service is provided: Verification of necessary priorauthorizations Verify patient meets medical necessity ESAs Track denials due to incorrect demographics & take corrective action to process/policy where necessary To minimize billing/collection problems Limit the number of staff members who can initiate changes in an existing patient s demographics Identify staff members who need to be notified of any changes made to patient s demographics 19

20 Name Address Date of birth SSN or other policy identifier Employer information Guarantor information Insurance information Primary or Secondary coverage Address for claims Provider number EDI payer ID Apply practice policy for patient assistance/ charitable care Reconcile patient accounts when patient assistance drugs or funds are received Track compliance with patient payment plans Apply established practice policy for collections Use appropriate adjustment codes when writingoff uncollectible claims Reconcile credit balances monthly 10/4/

21 Web-based tool Practice-specific with daily updated drug pricing Covers more than 500 referenced treatment regimens Customizable payer fee schedules Customizable supportive care drug regimens Body Surface Area (BSA) calculator Patient friendly financial responsibility reports 21

22 Uses real-time cost data Provides an estimate of financial impact for various protocols Eases burden of cost management for practice Identifies four key areas of need: 1. Patient-physician discussions regarding the cost of care are an important component of high-quality care. 2. Educational and support tools for oncology providers are needed to promote effective communication about costs with patients. 3. Patients need educational resources about the high cost of cancer care to help guide their decision making regarding treatment options. ASCO s Managing the Cost of Cancer Care Booklet is an educational resource to help patients raise these issues with their doctors. 4. ASCO needs to address the underlying factors contributing to the increasing cost of cancer care. 22

23 Information, tools and resources to help patients manage the financial impact of a cancer diagnosis Introduction on the Costs of Cancer Care Understanding the Costs Related to Care Questions to Ask about Cost Financial Resources Health Insurance Getting Organized Glossary of Cost-Related Terms National Resources Chronic Disease Fund Health Well Foundation National Organization for Rare Diseases Patient Advocate Foundation or Patient Services Inc. 23

24 National Resources Patient Access Network Foundation (PANF) National Cancer Institute American Cancer Society Partnership for Prescription Assistance Manufacturer-sponsored Patient Assistance Programs (PAPs) Check with each manufacturer US Social Security Administration Access to Benefits Coalition State Pharmaceutical Assistance Programs StatePharmaceuticalAssistanceProgramsNCSL20 0/tabid/14334/Default.aspx 24

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