Common Access Barriers to Care in Today`s Reimbursement Climate

Common Access Barriers to Care in
Today's Reimbursement Climate
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www.patientadvocate.org/gethelp
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Presentation Objectives
•
About Patient Advocate Foundation
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Overview of the Coverage Access Guide
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General Patient Tips for Streamlining
Healthcare
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Common Road Blocks
• Insurance Network
• Policy Changes
• Financial challenges
• Pre-approvals / Prior-Authorizations
• Workplace Concerns
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The Challenge of Specialty Drugs
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Resources
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What Does PAF Do?
MISSION: Patient Advocate
Foundation seeks to safeguard
patients through effective mediation
assuring access to care, maintenance
of employment and preservation of
their financial stability.
• Provide real-time help for
TODAY’s needs.
• Free assistance to patients,
caregivers, or their POC
• Personalized assistance
• Confidential and Security-aware
• Assigned Case Manager
• Engagement within 48 hours
• Short-term case duration
• Issues are focused in 3 areas:
• “Active liaisons” that work on behalf
of patient
• Phone-based interaction
Insurance | Financial Stability
& Medical Debt | Employment
Related
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Coverage Access Guide App
Coverage Access Guide: A Consumer’s Guide
to Insurance is designed to answer frequently
asked questions about accessing, enrolling and
maintaining healthcare coverage.
Download Now and
Access Additional Tips
During Presentation
FREE, user-friendly, article-based educational
guide geared to help current and future patients
overcome common healthcare obstacles in order
to enhance their overall healthcare experience.
Available exclusively in Apple‟s App Store for
iOS phones and tablets
Built to address the challenges that are
known to frequently occur for Narcolepsy
patients
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Helps patients avoid common insurance
pitfalls and overcome healthcare obstacles.
The mobile app covers
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Insurance Basics
Selecting Insurance and Enrollment
Key Vocabulary and Terms
Maximizing Coverage
Common Barriers
Clinical Trials
Patient-Physician Insurance Interaction
Disability Eligibility & Benefits, Workplace
Benefits, Patient Protections
Videos, links to resources and ability to share
articles with a friend
Also Available in
Print Form
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Impact of Obstacles
Time delay obtaining treatment,
medication and care
Financial impact; No access due to
upfront costs
Therapeutic non-compliance
Potential negative health outcome
and greater cost of care
Quality of Life impact; Workplace
Family
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Engaging With Your Medical Team
Be detailed and document often!
• Write down your questions before a visit
• Ask about clinical terms you don‟t understand
• Bring someone with you to help with
documentation and emotional support
• Ask your doctor about his experience
with narcolepsy
• Record notes of all interactions with insurer and
billing contacts
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Get Organized
Organizing your paperwork will save you time and
reduce stress in the future.
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Have a location designated for paperwork
Develop a filing system and storage area
Create a ‘cheat sheet’ of most important info that is
regularly accessed
Familiarize others with your system
Be prompt – stay on top of paperwork
Make a household budget
Estimate medical expenses, utilize health cost
calculators to understand out of pocket costs
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Common Roadblocks for Narcolepsy Patients
Top Issues From Patients Served at PAF
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Necessary Prior-Authorization not obtained
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Lack of documentation needed for Prior-authorization
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Not approved for off-label indication
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No medication coverage
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No insurance coverage / Lost coverage
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Need Pharmaceutical Copayment Assistance
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Unable to afford Insurance Premiums
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Unpaid medical bills
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Insurance Networks
Insurance plans vary in terms of network and
covered services.
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Be proactive to avoid future
challenges with insurance
plan details.
Providers
Specialists
Facilities
Diagnostics / Labs / Radiology
Pharmacy
Network is constantly changing, provider
relationships with insurer occur regularly with
limited notice
Plans may have limited or no Out-of-Network
coverage
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What can you do?
Dealing with Your
Insurance Network
• Become familiar with insurance- specific
terminology (co-payment, deductible,
etc.)
• Know your insurance plan language.
Communicate with insurer as often as
possible to understand network
• Always check if your provider, facility or
lab work is in-network beforehand, even
if you‟ve been seen before
• Look for plan with out-of-network
coverage in future
• Be familiar with insurance paperwork
formats like EOBs, claims, prior
authorizations, etc.
• Appeal if needed to treat out-of-network
provider with in-network rates
• Call Insurer if any questions
• Obtain needed referrals if necessary
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Insurance Plan Transitions
When:
Your plan is ending its plan term
Your employer-based plan is ceasing
Your are transitioning to a new plan
You are researching plan options and looking to
transition to a new plan
• Your eligibility for Medicaid/Medicare is changing
• You no longer meet coverage under family plan as
dependent
• You have a life event affecting your insurance
(marriage, divorce)
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Treatment may be
long-term, so review
insurance plan options each
open enrollment period….
…..even if you have been
happy with your insurance.
Why?
Better reimbursement for treatment
Better reimbursement for medications
Different network of providers
Lower out of pocket costs / deductibles
Health Savings Accounts / Flexible Savings Plans
Where?
Insurance Marketplace
Direct from Insurer
Federal programs – Medicare / Medicaid
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What can you do?
Choosing the best plan for you
• Insurer‟s website will have online druglookup area for each plan where you can
• Don‟t only look at monthly premium amount
• Review the plan‟s medication deductible and
out-of-pocket maximum for annual
medication expenditures
• Review pharmacy network options: mailorder service, local pharmacy, specialty
pharmacy
• Talk to doctor about medication supply
search for a specific medication
• Call Insurer if any questions about drug
tiers or formulary
• Pay attention to the drug formulary list
and those medications requiring priorauthorization
• Pay close attention to those medications
that are not covered
before transition to carry over until new plan
is in effect
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Financial Challenges
Those diagnosed with chronic conditions frequently have
challenges balancing financial obligations
Medical Visits & Care
Tests, Laboratory, Radiology
Medication Costs
Monthly Premium
Over-the-counter needs
Medical equipment
Food & nutrition
Combined with:
Decreased income due to time away from work
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What can you do?
Financial Challenges
• Communicate cost concerns with
doctor about non-compliance when
it comes to medication or care.
• Research disease-specific copay programs
• Adjust family household budget as
needed
• Talk to your doctor – Communication is Key
– and can open other avenues of assistance
known by provider
• Research savings programs and
financial assistance for other
household bills
• Keep an eye out for Coupons, Manufacturer
discounts or savings programs for all the
medication you are on (example AARP,
GoodRx, FamilyWize, etc.)
• Re-evaluate insurance plan each
open enrollment to look for better
coverage
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Insurance Approvals
In order to be covered, many plans require
prior-authorization submitted by provider in
advance of access
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Show medical necessity
Sleep study supporting diagnosis
Previous treatment results
Step therapy progression
Network pharmacy
Meet FDA approved indications
Time for approval
Access is limited without successful priorauthorization
Denial of prior-authorization can cause
delays in future access while resubmitting.
Affordable Care Act
guarantees your right
to right to appeal
insurance decisions.
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What can you do?
Insurance Denials & Approvals
• Address the defined reason for the
denial (i.e. alternative step therapy
• Be proactive! Don‟t wait till critical
medication supply to start process
• Gather appropriate medical documentation
and provider paperwork
• Obtain a copy of medical records from
previous providers, if relevant
• Copy of medical records showing complete
history of treatment and medications used
in the past.
requirements first)
• Seek medical journals or current
research that support your request.
• Meet deadlines for appeal paperwork
• Communicate and seek help from your
doctor gathering needed documents
• Seek help from an advocate
• Investigate alternate coverage options
through manufacturer during appeal
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Balancing Work & Medical
Programs are in place to protect your income and employment
while dealing with diagnosis
Family and Medical Leave Act
Allows you to take up to 12 weeks of unpaid leave and still be
eligible to return to work. You must have a qualified and
documented medical reason that applies to yourself or to a
child, spouse or parent for whom you are a caregiver
In addition to protecting your job, FMLA allows you to maintain
your group health insurance coverage as though you are still
actively at work.
Other Options:
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Americans with Disabilities Act
Short-Term Disability
Long-Term Disability
Social Security Disability
Insurance
Supplemental Security Income
Eligibility
You are eligible for FMLA leave from your job when:
• You have worked at least 1,250 hours in the past
12 months for your employer, even if the hours
were not in consecutive months.
• The company employs 50 or more employees
within a 75-mile radius
• Employers do have the right to require that you use
your paid vacation and sick time before you are
allowed to take unpaid FMLA leave; this policy is
usually documented in the company‟s policy
handbook.
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Most Common Medication
Related Barriers
Affordability and cost concerns related to
medication are very common.
In 2014
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53.29% of patient cases in our case
management division called specifically with an
issue related to medication access and drug
affordability
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14% of uninsured issues involved no coverage
for needed medication
“Headlines consistently warn that
prices for prescription drugs are
spiking higher and higher. Half
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Being able to afford your medications is key to
adhering to a treatment plan, which affects
everyone across all social barriers.
of Americans are taking
prescriptions regularly.“
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Why are Specialty Drugs
Challenging?
Not a ”typical prescription” experience ---
Some plans are
implementing a 5th Tier
or “Specialty Tier”
Can
be %
of
drug
total
cost
• Special handling, administration or
monitoring
• Terminology, process, reimbursement
• Limited distribution sites
• Prior authorization required;
increasing number not covered
• Higher patient financial responsibility
• For chronic or difficult health
conditions
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Insurance Tiers
--------------------------------Updated yearly, although
subject to change at any
point. Medications may be
reclassified to a new tier, or
dropped all together from
formulary.
Paid Upfront Before
Access
------------------------------------Patient may also have drug
benefit-specific deductible to pay
before insurance coverage
begins. All pharmacies require
total payment upfront before
dispensing or releasing
medication to patient.
Co-payments and
Co-insurances are not linear
and may grow substantially
with tier level.
Noncompliant
with treatment
-----------------------Cost concerns can
push patients to not
fill a prescription, skip
pills, or otherwise not
take as prescribed
without doctor
awareness. This may
impact their care and
overall health.
Prior-Authorizations
---------------------------------For higher tier medications,
insurers require the patient to
go through a priorauthorization process to access
medication.
Step Therapy
--------------------------------------Even if medication is „covered‟ under
plan‟s tier, you and your doctor may be
required to attempt other medications
first or provide documentation as to why
this is not feasible.
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What can you do?
Get to know plan benefits
when it comes to medication
coverage.
• Insurer‟s website will have online druglookup area for your plan where you can
• Talk to you doctor about medication options
on lower tiers
search for a specific medication
• Call Insurer if any questions about drug
tiers
• Review pharmacy options: mail-order
service, local pharmacy, local pharmacy
coupon or discount programs
• Pay attention to those requiring priorauthorization and complete as required
• Appeal within Plan Language
• Request an “Exception to Formulary” List
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Where to go for Help?
?
Caring Voice Coalition, Inc. provides financial grants to alleviate the
burden of medication copayments allowing narcolepsy patients to
start and remain on their prescription therapies.
www.caringvoice.org
Narcolepsy patients now have somewhere to turn for assistance. This
program is designed to help all patients who need assistance when
dealing with the complications of a narcolepsy condition, including
insurance appeals and medication prior-authorizations.
Narcolepsy.pafcareline.org
866-538-7617
There are organizational resources available to specifically help patients with narcolepsy, their caregivers
and family members
Financial Resources for Medical Expenses
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Household Expenses
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Educational & Disease-Specific Materials
P: 800.532.5274
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Where to go for Help?
National Underinsured
Resource Directory
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Lists community organizations that provide grants or financial
assistance to help patients pay for medication and pharmaceutical
products.
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Search under categories of “Medication Assistance” or “Medical
Bills” and “General Financial Help”
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Unlimited searching
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Available with web access, mobile phone access
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35 areas of assistance available including insurance policy options,
financial assistance for housing, utilities and transportation, clinical
trial and medication assistance.
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www.patientadvocate.org/underinsured
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My Resource Search Mobile Phone App
www.patientadvocate.org/myresources
Or from APP STORE directly from your phone
My Resources
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What if Uninsured?
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Seek out “Free Drug” programs or “Indigent”
programs from manufacturer for uninsured
patients
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Look for pharmacy savings programs (ex: WalMart 4$ generics membership, Walgreens Savings
Club)
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Medication specific coupons, rebates or discount
cards
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Ask for medication samples from provider
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Look for financial assistance in other budget
areas to offset costs and free up money for
medications
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Search within PAF‟s National Uninsured Resource
Directory and matching publication for additional
tips
Tips for Dealing with
Uncovered Medications or
Uninsured Patients
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Questions?
Thank you!
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(800) 532-5274
www.patientadvocate.org/gethelp
P: 800.532.5274
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