Oncology & Hematology Coding Alert

Follow these 4 steps to safeguard a patient's financial and physical well-being.

Your patients shoulder a greater cost burden for medical care than ever before. In the last 10 years, insurance deductibles have more than doubled, premiums have more than tripled, and wages haven't increased accordingly. Is your oncology practice's revenue cycle equipped to handle the pressure?

Probably not. And chances are, your patients aren't, either, according to Dan Sherman, MA, LPC, founder and president of the NaVectis Group, which specializes in clinical financial navigation. Oncology patients routinely see catastrophic bills that they aren't prepared for. That puts their treatment, their mental health, and your facility's financial health in jeopardy, he noted at the recent Oncology Reimbursement Meeting of the Association of Community Cancer Centers in Richmond, Virginia.

The True Cost of Financial Toxicity

Expensive cancer treatments hurt more than a patient's bank account. Consider these statistics:

• Patients with medical debts may delay or forego additional care to avoid racking up even more medical bills, according to a 2016 report from the Kaiser Family Foundation, "The Burden of Medical Debt: Results from the Kaiser Family Foundation/New York Times Medical Bills Survey."
• Indebted patients are more likely to cancel routine doctor appointments, delay follow-up care, and fail to fill prescriptions, according to that same survey.
• Patients with high co-pays (more than $54) were 70 percent more likely to discontinue treatment within six months, according to a study published in the Journal of Clinical Oncology.

Sherman calls medical debts and other monetary pressures that lead patients to forgo care "financial toxicity," and he says the tipping point is lower than you might think: In a widely publicized 2015 survey, the Federal Reserve found that fewer than half of Americans would be able to cover a $400 emergency expense without selling something or borrowing money.

Good to know: Part of the Oncology Care Model is implementing the Institute of Medicine care management plan, which details 13 issues to discuss with the patient. Although only one of those issues directly mentions the word "cost," there are financial components to almost all of those issues, notes Sherman.

Practices that sidestep frank financial conversations unintentionally sabotage their patients' future care-not to mention the bad debt write-offs that burden your practice or outpatient facility. But a dedicated, highly trained financial counselor can actually help safeguard a patient's financial and physical well-being, says Sherman. Here's how:

Step 1: Know the clinical details.

Financial counseling might be administrative in nature, but clinical knowledge is a must. Good financial navigation involves "combining the clinical needs of the patient with the patient's financial circumstances," says Sherman. For example, a large chunk of the oncology drug pipeline is oral medications. "What does that mean for Medicare patients? They use up their [drug] coverage immediately," he notes. A financial counselor must know things like that.

Go to the patient's physician and ask about things like the specific treatment, the length of treatment, and how harsh the treatment is, Sherman recommends. For example, you must know if the patient will be able to work. "If the patient has a certain income now and they won't be able to work in 6 months, help them now," he advises. "You can't wait until they get on COBRA, then have problems because they can't afford it."

Step 2: Help patients understand insurance coverage.

Patients want specific information delivered in simple terms. "What's my coverage?" "How much does this cost?" "How much will I owe?" "I can't afford that. What now?" are common patient questions that your practice staff must address. But most staff in this position are ill-equipped to do that, according to Sherman.

The standard response to confused patients is all too often "call your insurance company" and that is not right, he laments. For some reason in our culture it is acceptable when the answer is "Hmmm ... I don't know, call your insurance company," he continues. Think about it: If you met an oncologist and said "Hey, my mom has squamous cell carcinoma," they would never say "I don't know, why don't you call the National Cancer Institute," he notes.

Step 3: Help patients optimize their insurance coverage.

Some financial counselors' first instinct is to direct the patient to assistance or charity options. But Sherman says that trying to optimize the patient's insurance coverage should come before turning to external assistance. "Can you get them to better coverage with a different plan or combination?" he asks. "Yes, the patient could qualify for free drugs but why do that if you can optimize their insurance first and get their out of pocket way down?" he points out. If their financial responsibility is still unaffordable at that point, then go after external options.

If you're worried that there's liability involved when recommending insurance programs to patients-don't be. You're not actually recommending, Sherman says. You're educating the patient and walking them through all of the options, not actually signing them up for a plan.

Top tip: When it comes to drug coverage, you need help patients plan strategically, Sherman says. For example, with a Medicare patient he'd fill the most expensive medication first, activating the catastrophic care faster, and then the rest of the medications are free for the patient.

Step 4: Help patients navigate assistance programs.

Financial counselors should view charity as a last resort-something to turn to when other avenues have been exhausted. Sherman views patient assistance programs as band-aids: they help, but they don't always solve the affordability problem at its root. "If you can optimize their insurance, they may not even need those [programs]," he explains. Then, those resources can be put to use where they are most needed.

Don't forget: The Affordable Care Act cost-sharing subsidies are still around. The government funding has gone away due to the current administration, "but the insurance companies still have to pay them to patients," Sherman points out.

Financial Distress Screenings Are Just 1 Tool in Your Box

Financial distress screenings are "not a bad thing, but they identify the problem too late," according to Sherman. He prefers that a financial counselor visit with a patient before the patient even knows that he or she is in financial distress. "Start immediately," he says. "There are patients where we know that financial toxicity is coming their way." If you wait till the bills start coming, and just hand them a charity application, the patient may already be thinking about stopping treatment "We are not 'getting it' if we do it that way," Sherman emphasizes.