Patient Financial Navigators
NCI Dictionary of Cancer Terms 1
A person who works with patients and their families to help them reduce stress or hardship related to the cost of treatment for a medical condition, such as cancer. Financial navigators help patients understand their out-of-pocket expenses and what their health insurance plans may cover. Financial navigators may also help patients set up payment plans, find cost-saving methods for treatments, and improve access to healthcare services that the patient needs.
This newsletter will focus on the current issues that underscore the need for patient financial navigators as well as some best practice tips for staffing and workflow.
The Case for Patient Financial Navigators 2, 3, 4
According to a recent Commonwealth Fund report, "How Well Does Insurance Coverage Protect Consumers from Health Care Costs?," in late 2016, 28 percent of U.S. adults ages 19 to 64 who were insured all year were underinsured. Further, the survey found that half (52%) of underinsured adults reported problems with medical bills or debt and more than two of five (45%) reported not getting needed care because of cost. Underinsured individuals have health insurance, but their deductibles and health care costs are high in relation to their income and they experience a financial hardship to pay their out-of-pocket costs.
In their analysis, the Commonwealth Fund defines the underinsured adults as those who are insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 10% or more of income; out-of-pocket costs, excluding premiums, equaled 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income.
Premiums, Deductibles, Coinsurance and Out-of-Pocket Costs
Figure 1: KFF 2018 Employer Health Benefits Survey Kaiser Family Foundation
The most recent trends show the largest increase in patient costs are related to the growth in deductibles. The Commonwealth Fund reports the share of privately insured adults who had health plans without deductibles has fallen by nearly half over the past 13 years, from 40 percent in 2003 to 22 percent in 2016. At the same time, deductibles have grown in size. By 2016, more than 13 percent of adults enrolled in a private plan had a deductible of $3,000 or more, up from just 1 percent in 2003.
According to the Kaiser Family Foundation (KFF) 2018 Employer Benefits Survey, the average deductible for a worker in an employer health plan this year is $1,573, up 4.5 percent from $1,505 in 2017. And while deductibles have more than doubled from 2008 to 2018, wages have only risen 26 percent over that period.
The rise in annual deductibles was also reported in the article “Revisiting Out-of-Pocket Requirements: Trends in Spending, Financial Access Barriers, and Policy in Ten High-Income Countries” published in the National Institutes of Health (NIH), National Center for Biotechnology Information (NCBI) on May 18, 2018. That report found that on average, annual deductibles for employees who are only covering themselves increased from $602 in 2005 to $1478 in 2016. The report also found substantial increases in the maximum out-of-pocket (OOP) costs beneficiaries incur each year. In 2005, 33 percent of employees had a maximum of $3000 or more, but in 2016, this had risen to 66 percent.
The increase in deductibles has a direct correlation to financial toxicity as shown in the Commonwealth survey, adults with high deductibles reported problems paying medical bills at twice the rate of adults without deductibles.
Employee premiums also contribute to the rising cost of health care for individuals and families, as shown in figure 1, KFF reports that from 1999-2018 worker contributions to family premiums has increased 259%.
Protections under the Affordable Care Act (ACA) include annual maximum out-of-pocket limits for covered services in a plan year. Deductibles, copayments, and coinsurance go towards the out-of-pocket (OOP) maximum after which the health plan pays 100% of the costs of covered benefits. The out-of-pocket limit doesn't include monthly premiums, nor does it cover anything spent for services the plan doesn't cover. In addition, most health plans don’t include coinsurance paid for out-of-network services when calculating the out-of-pocket costs.
While ACA compliant plans can’t exceed the maximum-out-of-pocket limits, they can establish maximum out-of-pocket limits that are lower than these amounts.
The Department of Health and Human Services (HHS) uses a formula designed to keep premiums in check while keeping up with medical inflation. The out-of-pocket maximums for ACA compliant plans have increased each year since first established in 2014 when the maximum out-of-pocket limits were $6,350 for an individual, and $12,700 for a family.
In 2019, the maximum out-of-pocket limit is $7,900 for an individual policy (up from $7,350 in 2018), and $15,800 for a family policy (up from $14,700 in 2018). 5
Out-of-Pocket Maximum/Limit Increases in 2019
For the 2018 plan year:
- The out-of-pocket limit for a Marketplace plan is $7,350 for an individual plan and
- $14,700 for a family plan.
For the 2019 plan year:
- The out-of-pocket limit for a Marketplace plan is $7,900 for an individual plan and
- $15,800 for a family plan.
SHORT-TERM LIMITED DURATION INSURANCE 6, 7
Short-term policies were designed to provide medical coverage for people who experience a temporary gap in health coverage. The ACA exempted short-term, limited duration (STLDI) health insurance policies from the definition of “individual health insurance” under the ACA. For that reason, many of the ACA health insurance provisions do not apply to STLDI policies including:
- Guaranteed issue is not required
- Preexisting condition exclusions are allowed
- Essential health benefits are not required
- Annual and lifetime dollar limits are allowed
- Preventive services without cost-sharing are not required
- No minimum medical loss ratio in STLDI policies
In October 2016, federal rules were adopted that specified that STLDI cannot provide coverage for more than three months (including any renewal period), as of January 1, 2017.
On October 12, 2017, President Trump issued Executive Order 13813 entitled “Promoting Healthcare Choice and Competition Across the United States.” This Executive Order states: “Within 60 days of the date of this order, the Secretaries of the Treasury, Labor, and Health and Human Services shall consider proposing regulations or revising guidance, consistent with law, to expand the availability of STLDI. To the extent permitted by law and supported by sound policy, the Secretaries should consider allowing such insurance to cover longer periods and be renewed by the consumer.” 8
In response, the Internal Revenue Service, Department of the Treasury; Employee Benefits Security Administration, Department of Labor; and the Centers for Medicare & Medicaid Services, Department of Health and Human Services published a proposed rule on February 21, 2018 entitled “Short-Term, Limited-Duration Insurance.” And on August 3, 2018 the Short-Term, Limited-Duration Insurance final rule was published.
Effective for policies sold on or after October 2, 2018, the final rule extends the maximum period for which STLDI policies can be offered. The policies can now cover an initial period of less than 12 months, and insurers can renew or extend STLDI policies for an additional 24 months (for a total of not more than 36 months).
The final rule requires enrollment materials and the STLDI contract to include a consumer notice, in at least 14-point font that states: “This coverage is not required to comply with certain federal market requirements for health insurance, principally those contained in the Affordable Care Act. Be sure to check your policy carefully to make sure you are aware of any exclusions or limitations regarding coverage of preexisting conditions or health benefits (such as hospitalization, emergency services, maternity care, preventive care, prescription drugs, and mental health and substance use disorder services). Your policy might also have lifetime and/or annual dollar limits on health benefits. If this coverage expires or you lose eligibility for this coverage, you might have to wait until an open enrollment period to get other health insurance coverage.”
States have flexibility to limit the contract period or renewals and extensions of STLDI to less than that allowed under the final rule, but states cannot expand the duration and renewal of STLDI. Several states have already limited the contract period and/or renewals and extensions of STLDI to less than that allowed under federal rules. California, Hawaii, Massachusetts, New Jersey, New York and Oregon are among the states that currently prohibit the sale of short-term health insurance policies that lack protections for people with pre-existing conditions.
KFF Henry J Kaiser Family Foundation recently published a Fact Sheet, “ACA Open Enrollment: For Consumers Considering Short-Term Policies.” The Fact Sheet, available in English and Spanish explains short-term policies eligibility requirements, duration of coverage and renewability of coverage, potential limits on covered benefits, and other differences between STLDI and ACA-compliant plans.
PRIOR AUTHORIZATION CHALLENGES & RESOURCES 9, 10
Prior Authorization Challenges
In December 2017, the American Medical Association (AMA) conducted a 27-question, web-based prior authorization (PA) survey of 1000 practicing physicians (60% specialists and 40% primary care). Eighty-six percent of respondents reported that PA burdens have increased over the past year, with fifty-one percent reporting that they have increased significantly; eighty-four percent of reporting physicians described the burden associated with PA requirements as high or extremely high; and ninety-two percent of respondents reported cared delays associated with PA requirements.
The AMA survey findings are consistent with the ACCC 2017 Trending Now in Cancer Care Survey with fifty-one percent of respondents reporting that the percentage of services requiring pre-authorizations has significantly increased. 11
Health insurance companies often use PA to verify that expensive drugs or treatments are medically necessary and to reduce waste and errors. However, the recent PA survey conducted by the AMA shows that too often the PA process and documentation requirements are cumbersome and result in unnecessary treatment delays or denied patient care.
The need for improvement in the PA process is increasingly recognized across the spectrum of health care organizations and stakeholders. The AMA, with other national stakeholders, announced a collaborative effort to improve the PA process and reduce burdens associated with it.
On January, 17, 2018, the AMA, the American Hospital Association (AHA), America’s Health Insurance Plans (AHIP), American Pharmacists Association (APA), Blue Cross Blue Shield Association (BCBSA), and Medical Group Management Association (MGMA) and other national stakeholders released a Consensus Statement on PA reform, stating, “The prior authorization process can be burdensome for all involved—health care providers, health plans, and patients. Yet, there is wide variation in medical practice and adherence to evidence-based treatment. Communication and collaboration can improve stakeholder understanding of the functions and challenges associated with prior authorization and lead to opportunities to improve the process, promote quality and affordable health care, and reduce unnecessary burdens.”
In the Consensus Statement, the health care leaders involved in the collaboration outlined their shared commitment to industry-wide improvements to prior authorization processes and patient-centered care, and outlining their shared commitment to work together to:
- Reduce the number of health care professionals subject to prior authorization requirements based on their performance, adherence to evidence-based medical practices, or participation in a value-based agreement with the health insurance provider.
- Regularly review the services and medications that require prior authorization and eliminate requirements for therapies that no longer warrant them.
- Improve channels of communications between health insurance providers, health care professionals, and patients to minimize care delays and ensure clarity on prior authorization requirements, rationale, and changes.
- Protect continuity of care for patients who are on an ongoing, active treatment or a stable treatment regimen when there are changes in coverage, health insurance providers or prior authorization requirements.
- Accelerate industry adoption of national electronic standards for prior authorization and improve transparency of formulary information and coverage restrictions at the point-of-care.
Prior Authorization Resources 12
The AMA maintains a webpage dedicated to PA resources to support reform and improve practice efficiencies. This webpage includes information on AMA PA reform initiatives, and PA toolkits, videos, guides and webinars.
AMA Tips to Help Physicians Reduce the Prior Authorization Burden in Their Practice
- Check PA requirements before providing services or sending prescriptions to the pharmacy
- Establish a protocol to consistently document data required for a PA in the medical record - Uniformly follow a protocol to help avoid delays in patient therapy, prevent potential follow-ups with patients for additional information and minimize time spent on authorization.
- Select the PA method that will be most efficient, given the particular situation and available options - PA methods include standard electronic transactions, health plan portals, fax, telephone and secure email. Select the method that best fits your practice to reduce work flow disruptions.
- Regularly follow up to ensure timely PA approval - The PA process is still primarily manual, and a request could be lost in one of the many steps. Track your requests and follow up to prevent delays that can occur if information is lost or not received by payers.
- When a PA is inappropriately denied, submit an organized, concise and well-articulated appeal with supporting clinical information - You can increase your chances of success in overturning a PA denial by making sure all clinical information is included with the appeal, including any data that may have been missing from the initial request. For prescription appeals, think about adopting electronic prior authorization technology to further streamline the process.
The Association of Community Cancer Centers (ACCC) also maintains resources in their Financial Advocacy Toolkit including Financial Advocate Roles & Responsibilities, Benefit Verification & Prior Authorization Checklist and a Benefits Investigation Assessment Form. 13
MEDICARE ADVANTAGE (MA) PLANS – STEP THERAPY IMPLEMENTATION 14, 15
Generally speaking, step therapy is a utilization management tool designed to encourage the use of less costly medications before more costly medications are approved for coverage. Step therapy is a type of prior authorization that implements protocols that require patients to use preferred medications before using medications considered by the payer to be second-line or third-line. Private healthcare payers often implement step therapy to manage prescription drugs.
Until recently, Medicare Advantage (MA) plans were prohibited from implementing step therapy protocols. However, on August 7, 2018, CMS published a memorandum to Medicare Advantage (MA) organizations announcing that they are rescinding their September 17, 2012 HPMS memo “Prohibition on Imposing Mandatory Step Therapy for Access to Part B Drugs and Services,” and issuing new guidance that recognizes Medicare Advantage (MA) plans may use step therapy for Part B drugs, beginning January 1, 2019, as part of a patient-centered care coordination program.
In the August 7, 2018 Fact Sheet, Medicare Advantage Prior Authorization and Step Therapy for Part B Drugs, CMS defines step therapy as a type of prior authorization for drugs that begins medication for a medical condition with the most preferred drug therapy and progresses to other therapies only if necessary, promoting better clinical decisions.
CMS states, as an example, that by using step therapy, plans could ensure that Medicare beneficiaries begin treatment with a cost-effective biosimilar before progressing to a more expensive drug therapy should the initial treatment be ineffective. Under the new policy, MA plans will still be required to cover all medically necessary Part B drugs for Medicare beneficiaries. Step therapy will only be applied to new prescriptions or administrations of Part B drugs, Medicare beneficiaries currently receiving drugs under Part B will not have to change their medication.
Additionally, MA organizations may implement their own step therapy policies and procedures as part of utilization management where an applicable national and/or local coverage determination is silent on the matter. However, an MA plan remains subject to fee-for-service (FFS) Medicare’s step therapy policies and procedures when they are specified in a national and/or local coverage determination.
During the Medicare Open Enrollment period between October 15, 2018 and December 7, 2018, beneficiaries may choose a MA plan that includes step therapy if one is available in their area.
Beneficiaries unsatisfied with their choice can make a one-time election to go to another MA plan or Original Medicare from January 1 _ March 31st annually, they may also make a coordinating change to add or drop Part D coverage.
MA plans participating in Part B step therapy must disclose that Part B drugs may be subject to step therapy requirements in the plan’s Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) documents that are provided to enrollees prior to the Medicare Open Enrollment period to assist them in making plan selections for the upcoming year.
Furthermore, MA plans that include Part B step therapy must couple step therapy with patient-centered care coordination services that include discussing medication options with beneficiaries, providing beneficiaries with educational material and information about their medications, and implementing adherence strategies for beneficiaries on their medication regimen. MA plans will also be required to furnish rewards to beneficiaries in exchange for their participation in the drug management care coordination program.
Medicare beneficiaries enrolled in a MA plan with step therapy requirements, can ask the MA plan for an expedited exception if they believe they need direct access to a drug that would otherwise only be available after trying an alternative drug. According to CMS, exception requests will be completed as expeditiously as the beneficiary’s health condition requires, generally within 72-hours.
Legislative Initiatives: Prior Authorization and Step-Therapy
In response to the growing challenges of PA requirements, states are passing PA legislation to improve transparency and lessen the administrative burden. The AMA is also providing states and specialty societies with resources including the AMA’s model bill, the “Ensuring Transparency in Prior Authorization Act,” which was designed to make the PA process timelier and more transparent. 16
On October 10, 2018, a bipartisan group of more than 100 members of the U.S. House of Representatives signed a letter to Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma urging the Agency to review and improve prior authorization practices under Medicare Advantage (MA) specifically urging CMS to: 17
- Collect data on the scope of prior authorization practices — including denial, delay, and approval rates
- Issue guidance to MA plans to dissuade the widespread use of prior authorization and to provide direction to the health plans to increase transparency, streamline prior authorization, and minimize the impact on beneficiaries
- Ensure that prior authorization practices do not create inappropriate barriers to care for Medicare enrollees
Step-Therapy Edits 18
In a letter dated October 1, 2018, forty professional medical organizations, including the American Society of Clinical Oncology (ASCO), signed on to a letter regarding step-therapy and commending CMS for recognizing the need for stable patients to remain on their course of treatment and requesting that this protection be extended to both new and existing Medicare beneficiaries.
Several states have enacted legislation which maintains the ability for insurers to use step-therapy as a tool to manage utilization while also protecting patient access and excluding beneficiaries with existing prescriptions from step therapy requirements. 19
Practical Strategies - Implementing a Comprehensive Financial Navigation Program
Financial Navigation Team
The Financial Navigation Team will likely be comprised of several staff members including both clinical and business staff.
Financial Navigator duties may be divided among several staff members, this will be influenced by:
- Practice size,
- Patient demographics,
- Payer/plan coverage requirements, and
- Practice policies regarding patient assistance
The Financial Navigation Team should have a thorough understanding of:
- The oncology practice & services provided
- Key elements of medical coverage & benefits
- Individual payer coverage rules
- Practice finance and collection policies
Essential Financial Navigator skills:
- Excellent communicator
- A good listener
- Detail oriented
- Ability to advocate on patient’s behalf
- Unafraid to inquire about patient’s finances
- Ability to ask for payments in a professional manner
- Educate patients about their insurance benefits, co-pays, co-insurance amounts, and any insurance limitations
- Educate patients about practice financial policies:
- Expectations for co-pay, co-insurance collections
- Determine costs associated with treatment plans and identify areas of financial risk to the practice & patient
- Verify that treatment plans comply with payer medical policies
- Communicate findings to patient & patient care team
Prior Authorization (PA) Staffing
PA staff should have a thorough understanding of:
- Key elements of medical coverage & benefits
- CPT, HCPCS and ICD10 codes
- Basic medical terminology
- Any state legislation regarding PAs
- Individual payer coverage, PA and Step-Therapy policies
Facilitating & Streamlining the Authorization Process
- Ensure adequate staff dedicated to handle the authorization process
- Financial counselor/patient advocates, clinicians. Most oncology clinics employ at least one full time staff devoted to the PA process
- Authorization staff coordinate and communicate with clinical staff to limit denials due to treatment being received prior to obtaining a necessary PA (or exception for step-therapy etc.)
- Proactively enroll patient in patient-assistance program when appropriate
A thorough financial clearance process will lead to identification of patients who may be under-insured, have special payer coverage requirements such as prior authorization, step-therapy, tiered drug coverage or site-of-service restrictions for medical and/or drug coverage. Additionally, this process should identify patients who have not paid their premiums and are in danger of having their coverage terminated.
To efficiently identify potentially underinsured patients, Financial Navigators should focus on patients who are self-pay, Medicare only, those covered under a Medicare Advantage plan, patients with no Part D coverage, those with coverage under commercial plans, Health-Savings Accounts, Cobra, and Medicaid.
Through the financial clearance process, benefit coverage and limitations are identified, medical necessity of the written treatment plan is established, and documentation of the regimen relative to pathway adherence is verified. Required prior authorizations are obtained, and step-therapy and/or other utilization management requirements are identified.
In addition, the practice should establish a policy to routinely verify any changes to a patient’s coverage. It has become common practice to verify insurance coverage prior to each chemotherapy treatment. In particular, watch for changes in employment status or insurance coverage and perform a thorough review of insurance benefits, coverage policies & patient financial responsibility when the health plan or treatment plan changes.
Sample Benefits Verification Questions
- What date did coverage begin?
- Is the drug covered under the medical or prescription benefit?
- Is the drug/service covered for the patient’s diagnosis?
- Are biomarkers or other special tests required for coverage?
- If so, do you pay for the test?
- Is prior authorization (PA) required?
- If so, what is the duration of the PA?
- Do other utilization management restrictions apply (eg, quantity limits, step edits)?
- Are there any special distribution requirements (eg mandatory specialty pharmacy, mail order, etc.)?
- Are there any site-of-service restrictions?
- Does a deductible apply?
- What is the patient’s co-pay and/or co-insurance for the services?
- Does the patient have an out-of-pocket maximum?
- Are there any other benefit restrictions that apply?
After completing the coverage and benefits review, the Financial Navigation team member communicates with clinical staff to inform them of any restrictions or special requirements in accordance with the patient’s insurance plan and provides prompt feedback regarding any potential payer issues with the treatment order plan.
In addition, the Financial Navigation team member educates the patient about their financial responsibility, provides the patient with out-of-pocket estimates, functions as a liaison between the patient and payer, and works as a patient advocate to identify alternative resources for non-covered services and financial resources for the patient.
Sample Workflow - Treatment Plan
- Treatment plans are entered in EHR to include diagnoses, services/drugs ordered (including supportive care drugs), dosage, frequency, route of administration
- Authorization staff reviews treatment plan and reported diagnoses for compliance with:
- Payer’s Medical Policy
- FDA indications
- NCCN guidelines
- Compendia listings
- Special coverage requirements i.e. PA, step-therapy etc.
- If treatment plan does not meet guidelines clinical team is notified
- Alternate treatment options may be explored at this point
- If treatment plan meets guidelines and payer coverage, patient is provided an estimate of treatment cost, and decision to proceed with treatment is made by patient and clinical team.
2 The Commonwealth Fund. www.commonwealthfund.org. How Well Does Insurance Coverage Protect Consumers from Health Care Costs? Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2016. Accessed August 18, 2018.
3 KFF Henry J Kaiser Family Foundation. www.kff.org. 2018 Employer Health Benefits Survey. Accessed October 3, 2018.
4 The National Center for Biotechnology Information. BMS Health Services Research. Revisiting out-of-pocket requirements: trends in spending, financial access barriers, and policy in ten high-income countries. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5960112/. Accessed August 18, 2018.