Calendar Gy Practices Are Driving Physicians to Seek the Shelter Cof Hospital Employment
Total Page：16
File Type：pdf, Size：1020Kb
April 2012 cancerexecutives.org The Value of Dedicated Financial Coordinators By Teri U. Guidi, MBA, FAAMA, and Elaine Kloos, RN, NE-BC, MBA; Oncology Management Consulting Group s payers continue to tighten their requirements to Key Responsibilities and Functions reimburse providers for care, it is not surprising that Financial coordinators provide services for both medical and Acommunity cancer centers—in physician practices and radiation oncology and, depending on patient volume, can- The financial in hospitals—are increasingly looking for ways to ensure opti- cer programs may consider employing more than one finan- coordinator must mal financial performance. In addition, the evolution of cial coordinator in the cancer center. Key responsibilities of “accountable care” is shining the spotlight on the need to this staff member include: be an integral manage the quality of care as well as the costs. Accountable Insurance verification. Before the patient’s first visit is member of the Care Organizations (ACOs) will be expecting to pay for care scheduled, his or her current insurance enrollment must be in a new manner that will certainly heighten the pressure on verified. Some providers have access to electronic systems cancer center providers to receive all reimbursements appropriately due in for this verification, but few include all insurers’ information team, frequently a timely fashion. and some may be outdated. The initial information is gener- Today, a key best practice to ensure receipt of reimburse- ally captured by clerical staff. This function should be per- interacting with ments is to employ a financial coordinator. Due to the very formed each month without fail and both primary and sec- clinical, clerical, complex nature of oncology services (including the detailed ondary insurances should be verified. coding and billing for those services), it is vital for cancer cen- Pre-certification and pre-authorization. When the and billing staff. ters to have a dedicated financial coordinator for oncology. provider determines the treatment plan, this information These individuals serve on the front line for the cancer must be available to the financial coordinator as soon as center, working to maximize the likelihood of submitting a possible—either in paper format or electronically. Once the “clean” and payable claim for services. Financial coordinators financial coordinator receives this notification, he or she can also advocate for patients and assist them with accessing as begin the pre-certification or pre-authorization process. many outside services as possible to help minimize the Before a patient begins treatment, the financial coordinator financial burden of cancer care. should double check the patient’s insurance enrollment and Continued on page 3 > Understanding the Oncology Opportunity By Jessica L. Turgon, Senior Manager and Matthew R. Sturm, Senior Manager, ECG Management Consultants, Inc. ontinual reductions in payments to medical oncolo- Calendar gy practices are driving physicians to seek the shelter Cof hospital employment. For the unprepared health system, this trend raises a variety of questions related to the strategic and economic value of such an affiliation. However, as described in this Executive Briefing, the acquisition of medical oncologists can offer significant strategic value to an 19TH Annual Meeting organization. In addition, the economic realities of a hospi- tal-based practice can mean stability and security for an oth- JANUARY 23–26, 2013 erwise struggling practice and service line. for professional charges declined 30 percent. This reflects SAN ANTONIO, TX reductions in reimbursement levels, as well as a number of Grand Hyatt San Antonio Winds of Change: Financial Pressure practices shifting infusion services to the hospital setting. In 20TH Annual Meeting Medicare is the dominant source of payment for cancer serv- response to these trends, oncology practices have focused ices. Over the past several years, reductions in Medicare pay- on improving the efficiency of clinic operations. Today, most JAN. 29 – FEB. 1, 2014 ments for both professional services and infusion drugs have practices have maximized operational efficiency. However, SAN FRANCISCO, CA taken a big bite out of medical oncologists’ revenue. physician income remains under pressure. Palace Hotel Between 2008 and 2010, the median physician collections Continued on page 6 > update cancerexecutives.org | April 2012 3 The Value of Dedicated Financial Coordinators dinator then discusses any out-of-pocket costs for which the patient is respon- > Continued from page 1 sible. Unfortunately, out-of-pocket costs for patients continue to rise exponen- identify the patient’s specific insurance plan. The financial coordinator then tially as employers are passing on more of the healthcare costs to employees. obtains from the payer coverage benefit details related to the patient’s treat- Out-of-pocket expenses include co-insurance, deductibles, and co-pays. The ment. financial coordinator must approach this sensitive subject very much as a An organized financial coordinator will maintain a patient advocate, helping the patient understand that file or database for all major payers’ plans, updating …(The) financial many venues can be accessed to help patients if they are information periodically, to speed the pre-certification struggling with the cost of their cancer care. coordinator services brought and pre-authorization process. Included would be: At this meeting, the financial coordinator will also • Any policies or rules regarding medical necessity the cancer center a drug explain that patient co-pays are due at the time of for specific drugs (matching a patient’s diagnosis check-in. If patients need to work out alternative pay- value of $261,880 and to the approved list of conditions for each drug) ment plans, this information should be noted in their • Number of treatments permitted before renewing “protected” more than registration, so the check-in staff realizes the situation. the pre-authorization. In other words, all co-pays should be paid at check-in $1.7 million in charges The financial coordinator should keep a file on each so the check-in staff can smoothly perform all duties patient to ensure that pre-authorizations do not run out otherwise at risk… and not be involved in discussing various financial or expire and maintain a tickler system in order to re- details with patients. certify when appropriate. For patients who cannot meet the financial obligation, the financial coor- In regards to radiation therapy, more payers are requiring pre-certification dinator can discuss additional steps, including: for IMRT, SRS, SBRT, HDR, and any other special procedures. BID (i.e., twice • Payment plans. If the patient can cover the out-of-pocket expenses but a day) treatments, whether external beam or HDR, should also be discussed cannot necessarily pay them promptly, a payment plan can be set up. This with the payer prior to the start of treatment to ensure that the appropriate plan should be a written agreement that is signed by the patient. modifier is used in preparing the claim for service. • Secondary coverage. For patients covered by Medicare only, discussion Patient interaction. The next key step is meeting with the patient. Prior to and cost estimates for secondary coverage is warranted. This process can that meeting, the financial coordinator approximates the cost of the cancer include an application to the Medicaid program if the patient meets the patient’s prescribed treatment regimen. At the face-to-face meeting, the coor- Continued on page 4 > update cancerexecutives.org | April 2012 4 The Value of Dedicated Financial Coordinators Quantifying the Value > Continued from page 3 Because the financial coordinator position does not generate direct revenue, financial criteria. If the patient can afford a secondary insurance, such as getting approval to staff this position may be difficult. Regularly measuring AARP, the cost is typically much less than the 20 percent out-of-pocket the financial coordinator’s true value is an important step in justifying the that Medicare does not cover. financial coordinator position. The most convincing argument comes from • Applications for assistance. Many types of patient assistance programs drug replacement programs. These programs give the provider free drugs to are available. replace those given to qualifying patients. Although the scale of these pro- • Hospital assistance programs and/or charity care. The financial coordi- grams and their options have diminished in recent years, drug replacement nator should assist the patient with the paperwork and ensure it is for- programs still offer very direct and readily measured value. warded to the appropriate hospital staff. Additional benefits accruing from the financial coordinator’s efforts are • Co-pay assistance programs. Most of these programs require that best defined in terms of charges that would otherwise have been at risk for patients complete extensive paperwork. Patients must understand their non-payment due to non-coverage, lack of insurance, and more. And finally, accountability in this process and receive assistance as appropriate so the financial coordinators benefit cancer centers in terms of time saved from ball does not get dropped. reduced handling of denials and appeals. Infusion services data that could be realized annually from a community Team and Staff Interaction cancer center employing a financial coordinator