Reframing Financial Navigation During COVID-19

On July 29, the ACCC Financial Advocacy Network hosted an interactive virtual town hall: Financial Navigation During the COVID-19 Crisis: Tips from Financial Advocates. Chair Lori Schneider, Oncology Operations Manager at Green Bay Oncology, moderated a panel discussion and Q&A with Rifeta Kajdic at St. Luke’s Cancer Institute and Angie Santiago, CRCS, at Sidney Kimmel Cancer Center.  

After the Town Hall concluded, Schneider, Kajdic, and Santiago reconvened to address the attendee questions they did not have time to discuss during the town hall.  

Our team is going to start talking to patients about cost estimates and out-of-pocket responsibilities for their treatment. Do you have any suggestions about this? Should we give patients any paperwork during these conversations? 

Kajdic: Oncology estimates are tough for uninsured patients. For insured patients, there are different contractual agreements, so there are lots of factors to take into account. For estimates, I recommend starting with radiation, since those CPT codes don't change much, and the cost per CPT code is going to be the same across the board. Try to use your health record and maybe pull data for specific CPT codes to determine the average cost per payer. If a patient is insured, then it will be easier, as you will be able to review patient benefits and explain what the patient’s out-of-pocket costs/deductibles are.  

Schneider: I feel it is beneficial to provide the patient with something to take home and review. Patients are already overwhelmed , and trying to understand insurance in addition to what they are hearing about with their cancer is difficult. When looking at chemotherapy out-of-pocket costs, I would consider getting the price for one treatment cycle and then explain that even though the doctor has ordered X number of cycles, they should keep in mind that they will only be responsible for their out-of-pocket maximum.  Also be sure to provide your business card or phone number so patients can call you if they have questions. 

Santiago: We provide patients with a printout of their insurance benefits for their infusion services. That way, they have a hard copy of how their insurance covers infusion between coinsurance, copay, deductible, and out-of-pocket. We also provide any additional paperwork that might be helpful. For example, if we are meeting with a patient and see an opportunity for assistance through a foundation such as the Leukemia & Lymphoma Society, we will provide paperwork about that foundation. That will give the patient a better idea of what the foundation can assist with. If we want to encourage a patient to apply for charity care for past hospital bills, then during our meeting we will have the application ready to give to the patient. We also provide our business cards in case we can be a resource for patients in the future.  

Are you currently meeting with patients in person or virtually?  

Kajdic: We are phone-screening all our new patients to address their needs/concerns/questions. For patients who are in dire situations and need to meet in person, we evaluate them to determine if it is safe to meet face-to-face. We have a consult room that is deep-cleaned and wiped after every entry. Patients must be masked and pre-screened for COVID-19 symptoms, staff must be fully gowned with masks and face shields/goggles, and both must maintain appropriate distance. These in-person meetings are reserved for patients with limited computer or internet access, a language barrier, or another extenuating circumstance.  

Santiago: Prior to COVID-19, we met with patients face-to-face in the clinic. Currently, the financial advocacy team is completing assessments over the phone. These phone calls start with an introduction of the financial advocate as part of the support team. We advise patients what their medical coverage is for infusion services. Then we assess patients for their ability to afford their copays and the availability of any foundation funds or charity care. If there is a need to see the patient, then staff members wear masks and shields at all times. However, we rely heavily on the front desk staff to obtain additional documents that may eliminate the need for face-to-face contact. 

Is there a good benchmark ratio for the number of physicians in a practice to the number of financial navigators in a practice? 

Kajdic: As we are always in need of more resources, the measure we tend to look at most is patient volume, which is a more accurate gauge of our FTE needs. We also use our productivity tracking data, such as pulling reports from EPIC to demonstrate how many treatment/therapy plans each clinic worked on and finalized, etc.  

Schneider: Check out ACCC’s Making the Business Case for Hiring a Financial Navigator, a guide for capturing the metrics that can demonstrate the return on investment of hiring financial navigators. 

How do you track copay reimbursement? 

Kajdic: We use EPIC at our facility and have created a process that makes tracking co-pay assistance and free drugs easier. In EPIC, treatment/therapy plans are driven to work queues (WQs) via referrals. We worked with our EPIC build team to incorporate “flags” for referrals of patients who receive co-pay assistance or free drugs. These flags automatically drive patient accounts to relevant WQs that our patient financial advocates (PFAs) have access to. For patient accounts flagged for free drugs, EPIC automatically adds a “Do Not Bill” note to the account.  

Then PFAs make sure the drug price is adjusted before claims/statements go out the door to payers/patients. For patient accounts flagged for co-pay assistance, PFAs bill the co-pay assistance after the payer has processed their portions. 

Prior to these system changes, PFAs maintained an Excel spreadsheet that needed to be manually checked to determine if a patient actually came to their appointment, and that list needed to be closely monitored to ensure that correct claims were billed and statements were sent. Now these flags are linked to completed patient visits, which makes the workload easier to track and execute. 

Schneider: Foundations are built into our system as payers, so we can track dollars coming in by running a report on those payers. We have one person from our revenue cycle department who manages all payments and processing of claims being sent. 

Santiago: Tracking co-pays, foundation billings, and reimbursements are all done manually by the financial advocacy team. We keep a spreadsheet of all patients who are enrolled in patient assistance programs. On a weekly basis, we review these patients’ self-pay balances to determine if any accounts/claims are eligible for approved patient assistance programs. We track all submitted claims on a spreadsheet, recording payment dates and payment amounts. We also ensure that payments are posted to the correct infusion accounts. On a monthly basis, we report to leadership the total amount of payments received. We also follow up with different patient assistance programs regarding any payments not received within a certain timeframe.  

If there are no financial grants available at the time you meet with a patient, how do you track that patient to check for available resources in the future? 

Kajdic: This is THE question. For our Medicare population, we must seek foundation assistance first before attempting to enroll a patient in a manufacturer’s free drug program. Manufacturer companies who have a PAP (patient assistance program) available will offer free drugs only after all other options have been exhausted. In the case of oral chemotherapy, whenever we enroll a patient in a manufacturer’s free drug program because foundation funds are unavailable, in theory that patient wouldn’t have to be reevaluated until it was time for them to be reenrolled in the program. However, if foundation funds were to open a month later, that patient could apply for those funds to have their copays covered.  

We can enroll commercially insured patients in manufacturers’ copay programs right away, provided that the patient meets the eligibility guidelines.  

Short of having a dedicated program for assistance tracking (e.g., TailorMed, Vivor, AssistPoint, etc.), there aren’t many methods out there other than keeping a manual list of the patients you have enrolled into free drug programs and their respective diagnoses, and then cross-referencing your list whenever a disease-specific fund opens. Depending on your electronic health record, it may be worth partnering with the team responsible for building modifications to your EHR (i.e., your “build team”) to see what opportunities and capabilities your system may have to monitor the availability of funds.  

Santiago: We use a spreadsheet and prefill it with all the patient information we gather when we first screen patients. Be sure to include patient diagnosis in your spreadsheet. That way, you can filter your searches by diagnosis and go from there. 

What resources are available for better understanding Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI)? 

Kajdic: We recommend you become familiar with your state’s websites for these programs, as they have the most up-to-date information and applications.  

Santiago: Triage Cancer’s Quick Guide to Navigating SSDI and SSI provides useful information related to common questions about SSI and SSDI. 

For more information, access a recording of the town hall, Financial Navigation During the COVID-19 Crisis or read a recap of the live Q&A.