Northwest Georgia Oncology Centers, P.C. High Deductibles and Out of Pocket HSA/HRA Plans (No up front collection) Medicare Advantage Plans Healthcare Exchange Plans Medicare only Cobra plans/high premiums
NORTHWEST GEORGIA ONCOLOGY CENTERS P.C. 2014 Challenge Healthcare Exchange Plans
North Shore Hematology / Oncology Associates 14 Medical Hematology / Oncology Physicians 2 Radiation Oncologists 7 Locations Conquering Cancer Close To Home
Benefit Counseling In over 3 years since providing benefit counseling our practice has helped over 500 patients obtain their medications and treatments while facing financial hardship: Over 400 grants through co-pay assistance foundations (over $3M in grant funds) Over 80 patient s were able to obtain a free supply of their medication for up to 1 year Over 40 co-pay cards activated through various pharmaceutical programs Over 100 patient s who were counseled on insurance options and were able to obtain the most beneficial plan available for their needs
Identifying Underinsured or Uninsured Patients Physician Order / Authorization Order is written for course of treatment Physician first identifies a patient who needs assistance Medicare only (20% co-insurance) No insurance or about to lose insurance Order is submitted to the authorization department Verification of Benefits Insurance coverage is re-verified if it has not been verified within the last 30 days Helps to understand exact position before treatment is started: Deductible Out-of-Pocket Co-Insurance (%) Determine what, how much, and with which assistance program best suits their situation
Patient Discussion: Coverage & Cost Explaining Coverage Education on insurance coverage deductible out-of-pocket co-insurance Difference between co-pay/co-insurance Routine follow-up with physicians (office co-pays) Other insurance options depending on time of year, plan, etc Explaining Cost of Treatment Possible costs for treatment (estimated $) Agree to pay or request a payment plan Discussion of financial information which may be used to acquire co-pay assistance: Household size Income Change of Income Insurance carrier Determine which assistance program is best suited based on insurance, diagnosis, and drugs
Co-Pay Foundations: +Cancer Care Co-Pay Assistance +Chronic Disease Fund +Healthwell Foundation +Leukemia & Lymphoma Society +National Organization for Rare Diseases (NORD) +Patient Access Network +Patient Advocate Foundation +Patient Services Inc Co-Pay Cards: Amgen First Step Genentech Drug Programs: +AZ & Me (Astra Zeneca) +Celgene Patient Support +Commitment To Access +Connection To Care +First Resource +GlaxoSmithKline (GSK) +Johnson & Johnson +Safety Net Foundation
Identifying Available Assistance: Step by Step Diagnosis Drug Insurance Carrier Uninsured / Denied Coverage Private / Commercial (Underinsured) Federal / State (Underinsured) Manufacturer Co-Pay Card Co-Pay Assistance Co-Pay Assistance
The Application Process: Start to Finish Pre-Qualification Pre-qualification screening on patient s behalf Review information, sign, submit proof of income and copies of insurance cards Pending applications are checked daily to verify all information Checking daily allows for immediate action once approved or denied assistance Approved / Denied If approved for assistance all related parties involved are made aware: Patient / Family Billing Department (Buy & Bill) On Site Pharmacy (Dispense Drug) Authorization Department Reimbursement claims are handled by our staff If denied assistance we explore other avenues where patient criteria may be met No assistance - a manageable payment plan
With an on-site pharmacy patient s have access to multiple medications Over 10 Injectable Drugs Immediate dispense of medications once approval has been obtained Receive their medications without any out-of-pocket expenses due to assistance Over 9 Oral Chemotherapy Drugs Patient s do not have to pay upfront and then seek reimbursement on their own behalf
Viable Insurance Options Patient s are educated on insurance options Best option is sometimes a more encompassing coverage plan Assistance may not always be available as funding can close at any time Co-Pay Assistance should never be looked at as a deterrent for better insurance coverage Medicare Only Responsible for 20% on every service Options for a secondary plan through such coverage as AARP or Medicaid Medicare Advantage General out-of-pocket expenses between $3,400 to $6,700 with a co-insurance from 10%-30% Open Enrollment (October 15 th - December 7 th ) Dis-Enrollment (January 1 st - February 14 th ) No Insurance Options such as Medicaid or as of 2014 The Exchanges through the Affordable Care Act
The Affordable Care Act Enactment & Impact Difficulty to ascertain coverage, benefits, and whether authorization/referrals are required Verification of insurance took sometimes up to a half hour for a single patient Conflicting benefits from customer service representatives ID# s given to patient s were not in the carriers system Applicants plan choices were incorrect Failure to verify benefits led to a delay in active patient s treatment s from the end of 2013 Concerns Not informed or educated on plan terminology and how it effects their care Not all of a patient s physicians are in one plan forcing a patient to find new physicians Applicants are picking plans that they cannot afford and do not provide adequate coverage: $2,200 deductible, $5,800 out of pocket, with a 30% co-insurance. Premium of $400 Inconsistency with hospital privileges and physician privileges in the same areas
Thank You
FINANCIAL BENEFIT COUNSELOR ORAL CHEMOTHERAPY OBSTACLES Brian Spohn Patient Advocate, The Zangmeister Center bspohn@zangcenter.com
OBJECTIVES Prior Authorizations Insurance mandating Specialty Pharmacies Co Pay Issues Uninsured patients
PRIOR AUTH PROCESS Retail Pharmacy will receive rejections stating Prior Authorization is required Pharmacy calls and notifies Physicians Office of PA requirements Physicians office staff calls PA help desk to request Prior Authorization, completes via faxed forms or over the phone PA determination can take up to 72 business hours and pharmacy and physician should be notified via fax or automated out bound phone call of decision
SPECIALTY PHARMACIES Some Commercial Insurances mandate patient to utilize contracted pharmacies Delays patient therapy No communication between SP and Physician Office
CO PAY ASSISTANCE Enroll patient in Pharma Program to verify coverage. Check to see if Pharma Company offers Co Pay Card Enroll patient in Non Profit Foundations to assist with Co Pays
CHARITABLE FOUNDATIONS AVAILABLE Financial assistance may be available from independent charitable foundations for qualified patients who are unable to afford the copay costs associated with oral therapies Below is a list of the foundations that may be able to provide financial support
UNINSURED PATIENTS Enroll into Pharma Program Obtain documentation necessary to complete enrollment Patient receive medication directly from Pharma Program or pharmacy
QUESTIONS