North shore hematology / oncology associates

Northwest Georgia Oncology Centers, P.C.
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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
Verification of Benefits
 Order is written for course of treatment
 Insurance coverage is re-verified if it has
 Physician first identifies a patient who
needs assistance
Medicare only (20% co-insurance)
 No insurance or about to lose insurance
not been verified within the last 30 days
 Helps to understand exact position
before treatment is started:

 Order is submitted to the authorization
department
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
Explaining Cost of Treatment
 Education on insurance coverage
 Possible costs for treatment (estimated $)

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
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
 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:
Co-Pay Cards:
+Cancer Care Co-Pay Assistance Amgen First Step
+Chronic Disease Fund
Genentech
+Healthwell Foundation
+Leukemia & Lymphoma Society
+National Organization for Rare
Diseases (NORD)
+Patient Access Network
+Patient Advocate Foundation
+Patient Services Inc
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
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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
Patient’s do not have to pay upfront and
then seek reimbursement on their own
behalf
Over 9 Oral Chemotherapy Drugs
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
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Medicare Only
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Responsible for 20% on every service

Options for a secondary plan through such coverage as
AARP or Medicaid
Medicare Advantage
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General out-of-pocket expenses between $3,400 to
$6,700 with a co-insurance from 10%-30%
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Open Enrollment (October 15th - December 7th)

Dis-Enrollment (January 1st - February 14th)
No Insurance

Options such as Medicaid or as of 2014 The Exchanges
through the Affordable Care Act
The Affordable Care Act
Enactment & Impact
Concerns
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Not informed or educated on plan
terminology and how it effects their care
Verification of insurance took sometimes up to
a half hour for a single patient
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Not all of a patient’s physicians are in one plan
forcing a patient to find new physicians
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Conflicting benefits from customer service
representatives
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ID#’s given to patient’s were not in the carriers
system
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Applicants plan choices were incorrect
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

Failure to verify benefits led to a delay in active
patient’s treatment’s from the end of 2013
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Difficulty to ascertain coverage, benefits, and
whether authorization/referrals are required
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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
[email protected]
OBJECTIVES
Prior Authorizations
Insurance mandating Specialty Pharmacies
Co Pay Issues
Uninsured patients
PRIOR AUTH PROCESS
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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
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Some Commercial Insurances mandate
patient to utilize contracted pharmacies
Delays patient therapy
No communication between SP and Physician
Office
CO PAY ASSISTANCE
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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
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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
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QUESTIONS