The Lynx Group

Leveraging Financial Advocates to Improve Patient Care

April 2017, Vol 8, No 2

St Louis, MO—Financial counselors can help patients find assistance with the often-prohibitive costs of cancer treatment. According to Jordan Karwedsky, a financial counselor at HSHS St Vincent Regional Cancer Center and Green Bay Oncology, Green Bay, WI, patients at these organizations saved more than $1 million on intravenous and oral chemotherapy in 2015 through copay assistance.

“That’s money in the door to the clinic and the pharmacies, and money the patient doesn’t have to worry about. This is why clinics need financial counselors—we kind of pay for ourselves,” Ms Karwedsky said at the 2016 annual meeting of the Association of Community Cancer Centers.

The session was moderated by Dan Sherman, MA, LPC, of the NaVectis Group in Grand Rapids, MI—a consulting company that assists oncology groups in implementing financial navigation programs as a response to the growing financial toxicity and distress that have become huge issues for patients.

“The world of financial navigation and health insurance has become much more complex, and having experts in place that can address this issue from a professional standpoint is essential,” Mr Sherman commented.

Ms Karwedsky is part of a 6-person team of financial counselors at HSHS St Vincent Regional Cancer Center and 6 other clinics in the area. Her team works alongside medical oncologists and other members of the cancer care team.

Starting Treatment

All oral and intravenous chemotherapy and radiation therapy treatments flow through the financial counselors before the patient starts treatment. “We have guidelines for our physicians, so they give us the time we need to get authorizations in place,” Ms Karwedsky said.

“We have 5 days to obtain authorization for patients who are just starting treatment, and 3 days to obtain authorization for a change in treatment; however, if a treatment is emergent, they can often get it authorized more quickly,” she said.

The financial team reviews the appropriateness of the prescribed treatment according to the National Comprehensive Cancer Network (NCCN) and Medicare compendia and medical insurance policies, and then contacts the insurance company for authorization.

“We take it a step further with oral chemotherapy coordination,” she said. “From the time the patient hears they’re starting oral chemotherapy to the time the drug is delivered to the patient’s home for the first time, the financial counselors have their eyes on the prescription.”

At the patients’ initial appointment for a new oral chemotherapy drug, a member of Ms Karwedsky’s team explains insurance coverage and copay assistance, and notifies the patients when they can expect a phone call from their specialty pharmacy. The financial counselor is also in ongoing communication with the providers, and informs them of the estimated time frame needed to get the medication to the patients.

After sending the prescription to the specialty pharmacy, the financial team works closely with the specialty pharmacy to ensure the prompt processing of the prescription. If directed by the pharmacy, the financial team will obtain prior authorization and apply for copay assistance, if necessary.

In addition, the financial counselors handle authorizations for molecular testing and diagnostic imaging, and are notified when a laboratory test is ordered or an imaging is scheduled.

Copay Assistance

If copay assistance is deemed necessary, a financial counselor will review the patient’s benefits, ascertain how much is left in the patient’s out-of-pocket maximum, and determine the best financial assistance program for the patients, choosing between copay assistance cards and national or local foundations.

“We always have copay assistance in mind when reviewing coverage for treatment, because it’s probably the most important thing for our patients,” Ms Karwedsky said.

Copay assistance cards offer drug-specific assistance through a pharmaceutical company. The patient must have commercial insurance coverage, and the drug must be used for an FDA-approved indication.

National or local financial assistance foundations offer disease-specific help for treatment and associated costs, such as transportation, for patients with commercial insurance or with Medicare coverage, and eligibility is based on household size and annual income.

The financial counselors at HSHS St Vincent Regional Cancer Center and Green Bay Oncology manage the application and reimbursement process for the patient. In addition, the financial team guides uninsured patients through Medicaid eligibility screening and with pharmaceutical company patient assistance programs, and connects them with various community programs and nonprofit organizations, such as NeedyMeds (www.needymeds.org) and other organizations.

Dealing with the Insurance Industry

When their providers wanted to standardize treatments in the clinics, they created chemotherapy pathways, and “the financial counselors were asked to be part of the process, because of our extensive knowledge of the insurance industry,” Ms Karwedsky said.

The counselor works with the physicians to develop treatment pathways that are aligned with the NCCN compendium listings. They focus on 3 key facets when creating these pathways—efficacy, health-related quality of life, and value.

Ms Karwedsky’s team also works with insurance companies, foundations, specialty pharmacies, and pharmaceutical companies to help them improve their programs, and help other regional cancer centers to establish their financial counseling programs.

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