Month: March 2022

What is a Copay Assistance Program?

As healthcare costs continue to rise, patients are looking for ways to save on medication costs. Providers want to make sure they get compensated for any patient out-of-pocket expenses due to them. When insurance is not enough to cover the total cost, patients struggling to afford expensive drugs turn to Manufacturer Copay Assistance Programs or Copay Cards to help with the out-of-pocket expenses. Pharmaceutical companies typically offer these programs. The program’s purpose is to help people with commercial or private insurance cover their deductibles, copays, and co-insurance directly related to the cost of their prescription drugs.

How do Copay Assistance Programs work?

Copay Cards reduce the total out-of-pocket expenses for the patient. Once approved for the program, the patient’s insurance is billed first and covers some of the drug’s cost, then the manufacturer covers most, if not all, of the remaining out-of-pocket expense.

How to apply for a Copay Assistance Program?

If your physician practice or specialty pharmacy does not partner with someone like Q Consulting Services, then the patient can access Copay Card programs through the manufacturer’s website. To sign up for the program, they will register online, or call the program to enroll. Once you are enrolled, you are provided with your member information and possibly a credit card to use at your pharmacy or provider’s office– this varies among programs.

If your practice/specialty pharmacy partners with a company like Q Consulting Support Services (QCSS) , we will sign up the patient and maintain their membership, and give you and the patient any information they need.

What are the requirements or restrictions?

For most Copay Card Programs, there are two main requirements:

1. The patient must have commercial or private insurance.

2. You cannot have government health insurance, such as Medicare, Medicare Advantage Plans, or Medicaid.

How to receive reimbursement for out-of-pocket expenses?

There are three possible scenarios:

1. The patient is filling their prescription (e.g., Humira) at the provider or hospital-owned specialty pharmacy. The pharmacist will process the patient’s insurance as the primary payer and the copay card as the secondary payer. The Copay Card Program may cover the out-of-pocket expense in its entirety, or the patient may be responsible for a tiny portion – generally around $5.

2. The patient is receiving an infusion (e.g., Herceptin, Stelara) at an out-patient facility. The facility will bill the primary insurance for the drug. Once the insurance company pays its portion, the explanation of benefits (EOB) will indicate the patient’s out-of-pocket expense. The patient is then responsible for submitting the EOB to the program. When the claim is approved, the program will mail a check or upload the reimbursement to a credit card.

3. QCSS can manage the entire reimbursement process, from electronically receiving the EOB as soon as the billing occurs, to and ensuring that the charge is loaded on the copay card and making sure the physician office is paid by either managing check requisitions or running the copay cards through your POS.

How do patients and healthcare professionals benefit from Copay Assistance Programs?

Copay Assistance Programs lessen the patient’s financial burden, making it easier for them to obtain their prescription and ensure that the appropriate treatment is attainable.

Q Consulting Support Services specializes in the management of Copay Card programs. Our dedicated staff partners with clients ranging from small oncology practices to the country’s largest healthcare systems. Our Support Service team enrolls the patient into the Copay Card Program, monitors and submits EOBs with patient out-of-pocket expenses, and follows-up on any denials to ensure payment is received promptly. Ultimately, increasing patient satisfaction and reducing the financial burden on the provider’s office or facility by guaranteeing patient out-of-pocket expenses are obtained, which reduces bad debt and increases revenue.

How to find Foundation Assistance for patients

Foundation Assistance for Chronic or Life-Altering Diseases

Foundations offer financial assistance to those suffering from Chronic or Life-Altering Diseases when insurance is not enough to cover the treatment. Foundations help fill the gaps by assisting patients with their out-of-pocket expenses.

What is Foundation Assistance, and Who offers it?

Non-profit organizations like The Leukemia & Lymphoma Society, Healthwell Foundation, and the PAN Foundation, to list a few, provide financial assistance to patients in need. These foundations offer specific disease funds and award assistance to patients via grants. The grants awarded may cover copays, deductibles, insurance premiums, co-insurance and may help with travel or household expenses.

Who is eligible for Foundation Assistance?

Available funding is disease-specific – you must be diagnosed with the disease, be actively receiving treatment in the United States, have insurance covering the medication and therapy, and fall within a certain percentage of the Federal Poverty Level Guidelines (FPL). Unlike Manufacturer Copay Assistance Programs, Foundations allow applicants to have Federally Funded insurance like Medicare and Medicare Advantage plans.

If your practice/specialty pharmacy partners with a company like Q Consulting Support Services (QCSS), we will enroll all qualified patients, maintain their enrolment, and manage the entire billing and collections process.

How to apply for Foundation Assistance?

Disease fund availability is dependent upon whether there is sufficient funding available. Funds open and close daily, making the application process more difficult than other financial assistance programs. If a fund is accepting applications, you should apply immediately.

Step 1: Gather Information for the application.

• Demographics (including Social Security Number)
• Diagnosis
• Estimated household financial income
• Insurance information
• Pharmacy contact information
• Treating physician contact information

Step 2:

• Apply online or over the phone.

Alternatively, QCSS can manage the entire process, from enrolling patients as soon as a fund opens and helping them manage their financial paperwork to ensure all claims are submitted and reimbursed promptly.

How much financial assistance can I receive, and how is it paid out?

The award levels range from $100 to over $10,000 per applicant, depending on the fund. The full grant amount is allocated over one year and reimburses for services and treatments rendered during this period via the fund’s reimbursement process.

Keeping your grant active

Foundations want to ensure that grants are being used by those actively receiving treatment and in need of financial assistance. Many foundations require initial reimbursement requests to be submitted within a specific time frame and do not allow extended periods of inactivity, or the awardee could lose the grant completely. The time frames vary between 90-120 days.

Q Consulting Support Services specializes in managing Foundation Grants for our clients. We actively monitor Foundation sites to apply for our patients as soon as a fund opens up. Additionally, we ensure that all reimbursement requests are submitted timely so that our patients do not lose their funding and may continue to pay their providers for services rendered.

How helping patients find financial advocacy improves patient satisfaction and reduces bad debt

How Patient Financial Advocacy Improves Patient Satisfaction and Reduces Bad Debt

Patient Financial Experience

The patient financial experience within the U.S. Healthcare System is unique due to the variety and complexity of the different payer-systems. A patient’s expectation of their medical bill being as straightforward as the treatment should not be unrealistic. However, it is not of this time. In combination with the complex nature of medical bills, the patient’s out-of-pocket responsibility has increased due to high deductible and high-cost sharing insurance plans.

A TransUnion Healthcare analysis revealed that patients are, on average, experiencing at least a 10% increase in average annual out-of-pocket costs, and the average burden on each patient is approximately $2,000 – an unaffordable hurdle for most patients that is leading to millions of dollars of bad medical debt for the average healthcare system.

Given the constant media attention about the burden of healthcare costs, patients are increasingly expecting their practitioner to either help them with patient financial advocacy or absorb some of the patient’s financial burden due to financial hardship. Therefore, it is in the best interest of all parties for the physician/hospital/pharmacy to provide financial advocacy services in tandem with clinical services to improve revenue recovery and patient loyalty.

Patient satisfaction and patient experience are inextricably linked. As patient out-of-pocket responsibility continues climb, the medical practices that take proactive measures to help meet the patient’s financial needs and improve the patient experience will be the practices to prosper.

Any practice that has attempted to provide in-house patient financial advocacy soon comes to realize the administrative burden that it puts on existing staff, and often are required to hire additional FTE’s to manage these programs on behalf of their patients. This is where Q Consulting Support Services steps in.

Q Consulting Support Services specializes in providing Financial Advocacy to help patients with the out-of-pocket expenses associated with treatment. Our dedicated staff partners with clients ranging from small oncology practices to the country’s largest healthcare systems. Our Support Service team applies for funding on the qualifying patient’s behalf through grants and financial assistance programs. After funding approval, we monitor and submit EOBs with patient out-of-pocket expenses, and follows-up on any denials to ensure payment is received promptly. Ultimately, increasing patient satisfaction and reducing the financial burden on the provider’s office or facility by guaranteeing patient out-of-pocket expenses are obtained, which reduces bad debt and increases revenue.

How QCSS was able to secure over $16,000 in financial advocacy for this patient

Patient Overview: Mr. V.

Like many newly diagnosed cancer patients, Mr. V’s life took a frightening detour when he was diagnosed with Locally Advanced Pancreatic Cancer at the age of 56. When he began treatment, he only had Medicare Part A benefits and had recently lost his job due to the COVID-19 Pandemic. His household income, which included his unemployment and his wife’s income, totaled about $2,000 a month, putting him at around 150% of the Federal Poverty Level.

Medication & Cost

The oncologist prescribed our patient Abraxane, Gemzar, and Creon to treat his Pancreatic Cancer and after consultation with Q Consulting Services and the hospital, he learned that his medications were going to cost him more than $12,000 a month, and did not have appropriate insurance coverage to help with the expense. For this couple on a fixed income, the cost would be impossible to cover. It was at this point that the hospital’s oncology business asked Q Consulting Support Services (QCSS) to step in, with the request that we help the patient avoid incurring an untenable amount of debt and assist the hospital in being reimbursed, where possible, for Mr. V’s treatment.

Outcome

The patient worked on getting additional insurance coverage and signed up for Medicare Part B., while QCSS simultaneously secured free drugs for Abraxane and Creon.

QCSS understands that a patient’s focus should be on their recovery while the physicians, nurse and hospital’s focus should be on patient care. With this in mind, we fully managed the entire enrollment, billing, and ordering process throughout Mr. V’s treatment, alleviating our client, The Greater Baltimore Medical Center, and the patient from this added burden. The patient received his medication for free, and our client avoided a potential loss of over $12,000 a month.

Once the patient secured his Medicare Part B insurance, QCSS then obtained a fund through the PAN Foundation to cover his 20% out-of-pocket expenses. Our client would be able to bill and receive reimbursement through Medicare, while our patient’s out-of-pocket costs were also fully covered.

This patient required more assistance due to the circumstances of his unemployment. QCSS provided further assistance by finding alternative funding options like The Good Days Emergency Relief Fund to help this patient with household expenses and utility payments.

Over three months, we were able to secure over $16,000 in financial advocacy for this patient. This patient was so appreciative of our services and the financial assistance we were able to provide through one of the most challenging times of his life. He focused on his health instead of stressing over the burden of expensive healthcare treatment

How QCSS was able to help Michael with $42,000 of medication costs

Patient Overview: Michael

Michael is a 50-year-old father of three with a combined family income of over $175,000 per year, who, in October 2020, was unexpectedly diagnosed with Chronic Myeloid Leukemia (CML). Michael had always been a healthy person and was not on any chronic-care medications, so while he had a great insurance plan, he had opted out of prescription coverage.

Upon learning of his diagnosis, Michael immediately enrolled in the insurance plan’s prescription coverage, but it would not become effective until January 2021

Medication & Cost

To Treat Michael’s CML, his Oncologist prescribed a Sprycel, an oral chemotherapy medication with a retail price of $14,130 for a 30-day supply, or, for Michael, a 3-month out-of-pocket cost of $42,390.

Michael was faced with either finding a way to afford his medication, choosing an alternate but less optimal medication, or delay treatment until his prescription plan began. The oncologist felt strongly that the patient begin the medication without delay but also understood the financial burden that it placed on Michael, so he contacted Q Consulting Support Services (QCSS) to help the father of three figure out what options might be available for affording this life-saving treatment.

The drug manufacturer offered a 30-day free trial, so QCSS immediately enrolled the patient into this option.

Challenges to Patient Assistance Program

The biggest hurdle in helping Michael with securing the next two months of medication at a price that he could afford was the combined family income of $175,000 a year. This level was above 500% of the Federal Poverty Level and pushed him outside of the eligibility level for the drug manufacturer’s patient assistance program (PAP).

October’s prescription was taken care of by the 30-day free trial, we QCSS had 30 days to figure out how we would secure November and December’s medication. After speaking with the territory pharmaceutical representative and stating the patient’s case, we learned that the only hope for assistance was through the manufacturer’s patient assistance program, despite his ineligibility

The Final Appeal

Even though the patient did not meet the income qualifications for assistance, we moved ahead with the application. QCSS’s Patient Service Advocate spent hours on the phone with the manufacturer’s PAP explaining the patient’s unfortunate circumstances. The foundation denied the patient’s application and notified us that the only remain would be to file an appeal on the patient’s behalf.

QCSS was transparent with both the patient and the physician throughout the entire process. There was no guarantee that we would be successful, but would do our best and go above and beyond in ensuring that all information about the patient and the financial hardship that would result in treatment was submitted. However, until the final appeal was heard, there was uncertainty if Michael would be able to continue his treatment and we wanted to ensure that both physician and patient were emotionally prepared for another denial.

A Successful Outcome

With this last-ditch option, many more hours on the phone, filling out applications, submitting financial documents, and making the patient’s case to the drug manufacturer, the free medication was approved!

How hospitals and oncology centers can reduce bad debt through Patient Assistance Programs, Copay Cards and Foundations

The ultimate goal of a hospital or healthcare organization is to provide exceptional patient care; however, making a profit is necessary to achieve that goal.

According to a survey from Sage Growth Partners, a healthcare research firm, more than a third of hospitals rack up at least $10 million in bad debt each year, and half do not expect to recover more than 10% of it from payors or patient out-of-pocket expenses.

Understanding Out-of-Pocket Expenses can be Complicated

Healthcare providers are more challenged than ever when providing quality care to an increasing number of patients facing unaffordable out-of-pocket costs due to high deductibles, being under-insured, or uninsured. With each of these financial hurdles, hospitals and medical practices face a tough decision:

1. Send the patient a constant stream of letters and notices informing them of their outstanding balance due

2. Write-off the payment as bad debt and carry it on their balance sheet with the expectation that payment is unlikely

Most patients’ bad debt accumulates because a patient cannot afford the balance after their insurance has covered its portion of the expense. Most medical insurance plans only cover part of the fee due to the provider, leaving the patient with out-of-pocket costs. These out-of-pocket costs include deductibles, coinsurance, and copayments.

Patients are often unaware of their out-of-pocket expense before their treatment, and in many cases, even if they are aware, they are unable to afford them. While it is ideal for a provider to collect all out-of-pocket expenses upfront, this is not always possible, especially for costly services like chemotherapy, GI infusions, and other expensive in-office injectables. The insurance carrier processes the medical claim first to calculate the patient’s responsibility and then reports it back to the provider on the explanation of benefits (EOB). It is then up to the provider to collect these payments by billing the patient.

Most organizations offer various options to make the payment process easier via patient portals and electronic payment options. However, these options are beneficial only if your patient can afford to pay. If the patient cannot afford their bill, they may qualify for a payment plan or financial assistance. Unfortunately, this extra step is not always enough, and the debt starts to mount.

Improving Cash Flow Management

Cash flow management is essential to all healthcare organizations’ viability, and their accounts receivable days are under constant measurement. Nearly all healthcare organizations bill insurance regularly to ensure ample cash flow and proactively send out a series of notices to patients to settle outstanding accounts. In these notices, the patient is instructed to submit payment within a given time frame. If payment is not received, the provider will send the patient to collections (likely lowering patient satisfaction scores). However, sending a patient to collections does not guarantee payment and usually just reduces the provider’s reimbursement because the collection agency imposes a fee for their services.

Using a billing and collection process as the only means to collect monies owed is inefficient and usually unsuccessful, particularly when patients cannot afford their bills. While it is essential to maximize collections, organizations must be careful not to take collection practices to an extreme. They risk alienating patients, receiving more patient complaints, and ultimately reducing collections.

There is a Better Way

There are many ways to avoid the ‘bad debt’ cycle that your practice might find itself in, particularly when helping patients cover their infusion and in-office drug costs. By taking advantage of many of the manufacturers, foundation, and non-profit support programs, it is likely that your patients will be able to find the help they need to cover their out-of-pocket costs.

Q Consulting Support Services – Patient Financial Advocacy

Q Consulting Support Services (QCSS) offers financial advocacy to patients through many financial assistance programs. We work closely with your clinical team to identify patients who are uninsured, underinsured, have high-out-of-pockets expenses, or high balances that qualify for assistance for their prescription drugs or infusion drugs. Below is a list of the most frequently used financial assistance routes; however, we are not limited to these options. QCSS has a comprehensive database of financial assistance programs we use to ensure we exhaust all avenues for our patients and clients.

Financial Advocacy Options:

Manufacturer Copay Card Assistance:

Drug Manufactures offer Copay Card assistance programs. The program’s purpose is to help people with commercial or private insurance cover their deductibles, copays, and coinsurance directly related to their prescription drugs’ cost.

Patient Assistance Programs:

These programs, frequently called PAPs, are designed to help those in need obtain their medications at no cost or very low cost. Many, but not all, pharmaceutical companies have PAPs.

Foundation Assistance – Copay and Premium:

Foundations offer financial assistance to those suffering from Chronic or Life-Altering Diseases when insurance is not enough to cover the treatment. Foundations help fill the gaps by assisting patients with their out-of-pocket expenses or covering costly insurance premiums.

Q Consulting offers a team of professionals that will find, source, and manage the much-needed financial assistance available to many of your patients. QCSS has a tremendous track record in reducing bad debt for providers through our financial advocacy program. One of our current clients reduced their bad debt by 70 percent within six months. Through this period, QCSS collected over $300 thousand in copay card assistance, $600 thousand in PAP (Free Drug/Replacement) assistance, and $200 thousand through other funding sources – adding up to over $1 million in financial advocacy found for this client.

If given the opportunity, QCSS will successfully help your organization recover patient balances through our financial advocacy program, ultimately reducing bad debt, increasing profits, and boosting available cash flow. We take the burden off your team so they can focus on what they do best-providing exceptional care to your patients.

Hospitals can improve infusion center profitability by focusing on one area – the Insurance Verification Process and Prior Authorizations.

Numerous factors have contributed to the shift of outpatient infusion services from the private practice setting to the hospital outpatient setting. As this trend continues, hospitals must focus on one area that can help guarantee the center’s profitability: verifying patient insurance benefits.

Many outpatient hospital-based infusion centers struggle to be profitable due to a lack of resources required to verify patient insurance. The verification process consists of three components: Verification, Eligibility, and Prior-Authorization.

Let us break down each component:

Step 1: Insurance Verification:

Does the patient have insurance, and are the infusion services covered under their plan? The intake department completes the verification process upon admission by calling the insurance carrier (which can be time-consuming), through the EMR system – if offered, or through another platform like Availity.

Verification of benefits ensures the patient has coverage for the specified treatment plan and indicates if prior authorization is required.

Step 2: Eligibility

During the insurance verification process, you must also determine the plan’s eligibility period. Is the patient eligible for services during the time that you will be performing the infusion? Completing this step before EACH infusion ensures there is no lapse in coverage or that the policy is still active and has not been terminated (which can happen for various reasons).

Step 3: Prior-Authorization (PA):

Once you have determined that the patient’s insurance plan requires prior authorization, you must ensure the patient meets the plan requirements. This process generally requires sharing information from the patient’s medical record. Providing the medical record will establish medical necessity and explain why the physician prescribed one drug over another more affordable option– possibly due to previous product failure or patient allergy. The health insurance company will review the physician’s recommendation and either approve or deny the authorization request.

It is imperative to note that medical care will need to be approved by the insurance carrier before treatment is received. The medical claim will be denied without prior authorization.

The prior-authorization process can be burdensome. According to the American Medical Association (AMA), 9 in 10 physicians find that prior authorizations have a negative impact on patient outcomes and believe the burden associated with PAs has increased over the past five years.

Revenue Cycle Management (RCM) and Prior Authorizations

Prior authorizations are a pain point for providers yet are crucial to the revenue cycle and clinical care operations. The RCM process ensures that patients can access the necessary care and providers get paid for delivering services.

Patient Revenue is tracked and managed through the RCM process, starting at the initial encounter through to the final payment. The cycle encompasses all administrative and clinical functions contributing to capture, management, and collections from the patient and their insurance provider.

Revenue Cycle Management is critical to operating a thriving infusion center; It requires the strategic management of Insurance Verification, Eligibility, and Prior Authorization. With the rising cost of drugs, shrinking margins, and overall changes in the drug and healthcare industry, providers need to be sure they have a knowledgeable team who can sustain a healthy revenue cycle.

Everyone plays a vital role in ensuring correct reimbursement for these high-cost drugs – but most organizations or infusion centers do not have adequate staffing or additional resources for such an undertaking.

Financial Advocacy – Supporting a Healthy Revenue Cycle

Q Consulting Support Services (QCSS) provides a team of financial advocates that can help the infusion center maintain a revenue cycle that maximizes revenue collection while keeping the patient at the center of each transaction.

QCSS is a full-service insurance verification, prior authorization, financial counseling, financial advocacy, and specialty pharmacy management program.

Most importantly, we begin by verifying insurance benefits so both the provider and the patient know the out-of-pocket expenses related to the planned treatment. Once our financial advocacy team identifies patients that are under-insured or have high out-of-pocket costs, we determine which supplemental coverage sources are available to help manage their healthcare costs and ensure the provider receives payment for services delivered. We continue to oversee the entire reimbursement process, whether for a Manufacturer Copay Card, Foundation Assistance, or Free Drug through a Patient Assistance Program.

QCSS will also manage the Prior Authorization Process to guarantee that patients get access to the medications they need on time – alleviating the clinical team’s administrative burden and allowing them to focus on patient care.

The revenue cycle in healthcare is complex, requiring continuous process improvements to keep pace with the ever-changing industry. QCSS would welcome the opportunity to partner with your infusion center to improve your revenue cycle and assist your staff and patients with all their financial assistance needs.

The negative impact of financial toxicity associated with cancer treatment related out of pocket cost.

Cancer Patient Risk Factors for Treatment-Related Financial Toxicity

Cancer is one of the most expensive medical conditions to treat in the United States. Patients that have been diagnosed with cancer will likely need multiple types of therapies, and many of these come with high out-of-pocket costs: chemotherapy, radiation, surgery, hospitalizations, systemic treatments, oral chemotherapy, and cancer-related prescription medications.

Further, cancer patients and survivors are often unable to work due to their treatments and overall health, placing more pressure on their financial circumstances.

Financial toxicity is how the healthcare world has come to define the financial hardship that patients experience due to their high out-of-pocket costs, which many have reported to be more than 20% of their annual income!

6 Factors That Increase the Likelihood of Patient Financial Toxicity

1) Age: < 65 years old

Cancer survivors under the age of 65 years are more likely to be financially impacted from cancer. This could be due to:

1. The lack of savings and assets

2. Other financial responsibilities like raising children

3. Not having health insurance

4. Having high-deductible plans with high out-of-pocket costs

2) Future Income Potential and Job Performance

This younger the demographic, the more likely their future job potential will be negatively impacted. Cancer treatments can impact a patient’s ability to work due to their therapy and overall poor health.

Cancer treatment requires frequent days away from work due to either treatment times that might include 4-hour chemo infusions, which decreases the patient’s work hours and overall productivity. Given this reality, cancer patients will experience difficulty returning to the workforce, often face job losses, reduced income, and employment-based health insurance loss. Cancer diagnosis and treatment takes a toll on the patient physically, mentally, and emotionally, diminishing the household productivity and income.

3) Income Level

Lower-income households are at a greater risk of treatment-related financial distress. The indebtedness of a patient before their diagnosis plays a significant factor in driving up financial toxicity. Cancer treatments will increase the patient’s risk of accruing more debt and often lead to difficulty paying for living expenses and an eventual filing for bankruptcy.

4) Other Chronic Conditions

Cancer survivors are more likely to have chronic conditions such as heart disease, high blood pressure, stroke, emphysema, high cholesterol, diabetes, and asthma, which alone are typically associated with substantially higher medical expenses. Layering a cancer treatment on top of these other expensive conditions exacerbates the financial toxicity levels that a patient is facing.

5) Advanced-Stage, Recurrent, or Multiple Cancers

The type and stage of a cancer diagnosis determine the treatment paradigm for a cancer patient. Advanced-stage, recurrent, and multiple cancers require chemotherapy and radiation that carry high out-of-pocket costs. Treating aggressive cancer or cancer with a poor-prognosis commits the patient to invest their financial resources for treatment and physician visits. Additionally, the patient will need to invest their time to attend appointments – which usually occur during working hours.

6) Health Insurance

The patient being uninsured certainly places them at risk for financial toxicity. However, the type of insurance coverage the patient has can increase the likelihood of economic hardship due to high maximum out-of-pocket and high deductible plans.

Patients with Medicaid or Medicare have a high financial vulnerability due to lower income levels and fewer savings and assets.

Financial Distress Reduction

The sharp and steady rise in cancer treatment costs has meant that patients need protection from financial toxicity. Financial toxicity can negatively impact the patient’s life outside of the clinic and interfere with the planned treatment strategy and overall recovery. As with any heavy financial burden, high medical expenses related to life-saving treatment carry the same destructive force and pressures and negatively impact the patient’s life, future, and ultimate outcome.

Patients with high financial stress show the following characteristics:

1. Decreased treatment adherence rate and increased prescription abandonment rate due to prescription copays and out-of-pocket amounts.

2. Lower Patient satisfaction scores

3. Reporting of more symptoms, including pain and feelings of depression.

Savvy practices that recognize the industry trend of financial toxicity on treatment outcomes, patient satisfaction, and overall general health will look for ways to solve these problems for patient s through financial advocacy and alternate solutions.

How Q Consulting Can Help

At Q Consulting Support Services, we provide the strategy, workflows and technology needed to obtain a more comprehensive picture of the patient’s financial status and find solutions to their financial toxicity burden. Our successful system decreases the patient’s out-of-pocket responsibility and reduces bad medical debt through unconventional patient funding sources. We can fill in the gaps through patient financial advocacy, so patients feel taken care of physically and financially to drive up patient satisfaction scores.

GI infusions for diseases like Crohn’s Disease are often required monthly and can be financially burdensome to patients. QCSS removes the financial burden from the patient by managing the entire copay card process.

Patient Background

Many patients we assist are dealing with chronic conditions requiring expensive medical treatment. This patient has been diagnosed with Crohn’s disease of the small and large intestines with complications. Crohn’s disease is an inflammatory disease affecting the digestive tract and currently does not have a cure. Infusion drugs can help manage the disease symptoms, but the treatment is expensive – even with insurance.

Financial Toxicity of Treatment Costs

Mr. R is a 22-year-old recent graduate just entering the workforce. He is still on his parent’s insurance plan, so his dad assists him with his medical care and decisions. His insurance plan has an out-of-pocket (OOP) maximum of $6,000 that he is responsible for paying annually. He is getting monthly infusions and will be accountable for each infusion’s OOP expenses up to his $6,000 insurance maximum. His first infusion had an OOP expense of $2,857.20, and his second had an OOP expense of $666.68.

The QCSS Copay Card Solution

Mr. R’s father called to discuss how Q Consulting Support Services (QCSS) could assist them with his son’s OOP expenses related to his Remicade infusions. QCSS’s Financial Advocacy team explained that we would immediately enroll Mr. R in the Remicade Copay Card Program. Moving forward, we will manage the reimbursement process from initial claim submission to receipt of payment directly to the provider’s office. Mr. R’s father could not believe what he was hearing and was highly appreciative of the services we offer, free of charge, through the hospital infusion center. The patient’s father said, “I know we have only been speaking for 8-minutes, but I think you are going to be my new best friend.” With one conversation, QCSS was able to save this family over $3,500.

The Typical Copay Card Reimbursement Process

A typical pharmacy copay card requires less patient involvement. The patient gives the copay card to the pharmacy, the pharmacy bills the insurance first, and then applies any remaining balances to the copay card. In contrast, the copay card process for infusion treatments can be burdensome and complicated – this is where QCSS steps in.

Usually, after a patient like Mr. R receives treatment at an infusion center, the practice will bill the patient’s insurance, and the insurance carrier processes the bill. As a result, the carrier generates an Explanation of Benefits (EOB), indicating payment to the provider and informing the patient of any OOP responsibility.

Each copay card program is different; however, the process for claim submission is generally the same. The patient has a certain amount of time to submit the EOB to the copay card program to secure the copay card payment benefit. The patient is then responsible for submitting the EOB, and many patients do not know what this is or where to find it. To ensure the claim is processed correctly, the patient must include the following information:

1. Reimbursement Claim Form
   1. Patient Demographics
   2. Name of the insurance provider & Member ID
   3. Facility Name, Provider Name, and NPI number
   4. Date of Service (DOS)
   5. Name of drug or J-code
   6. Amount billed, allowed amount, the amount paid to the provider, and patient responsibility.
2. Claim Form
   1. UB4
   2. CMS 1500 HCFA
3. Explanation of Benefits

Once the patient has gathered the claim information, the patient submits the claim by fax, mail, or online portal to the copay card program. Upon submission, the program verifies the claim. The copay card payment is processed – processing time can vary between hours, days, and weeks – regular phone calls to the copay card company are required to ensure the claim is processing correctly, and no further action is required.

After the payment is approved, the program releases the funds via check or credit card payment. If this process is not convoluted enough, the patient is responsible for coordinating payment to the provider. Suppose the payment is loaded to a credit card. In that case, the patient is responsible for calling the provider, giving them the date of service and amount due, then providing them the card information to process the payment. If the program issues a check payment, the patient can coordinate with the copay card company to have the check sent directly to the provider. It is then the responsibility of the patient to ensure payment is received and applied to their account.

Improving Patient Satisfaction

Mr. R was thrilled with the services provided by QCSS on behalf of the infusion center. QCSS manages the entire process – we identify EOBs with patient OOP expenses, then submit them to the copay card manufacturer on the patient’s behalf, and monitor processing to ensure payment is approved. If the program generates a check payment, we notify the provider of the check number and amount paid. If the program loads the payment to a copay card, QCSS communicates with the provider’s billing office and has them process the charge. QCSS updates Mr. R throughout the process, and any decision that is not in our patient’s favor is appealed and rectified. Our approach is entirely seamless, relieving the patient of this burden while ensuring payment is received for their bills– which is why the provider’s office loves the service!

Healthcare expenses related to diseases like Crohn’s Disease Mr. R” s, which require monthly infusions, are financially burdensome to patients and their families. This financial toxicity can create and add additional stress to an already stressful situation. Alleviating our patient and his family from the financial burden related to this treatment will allow him to continue treatment without delay and focus on the more essential things in life.

A how-to-guide to troubleshoot financial advocacy for cancer infusion center patients facing financial distress.

Patients who have insurance and are on expensive infusion therapy and oral chemotherapy medications must meet high out-of-pocket maximums before their benefits cover the treatment cost. Many patients find themselves with out-of-pocket maximums that exceed $6500 when seeking treatments for cancer or other infusion-related treatments.

As many headlines have noted, patients without insurance or prescription coverage face a shocking bill for their life-saving prescriptions. The retail price of a 30-day supply of oral oncology specialty medication is double and triple the out-of-pocket maximums – and can be as much as $16,000 for a month supply.

Fortunately, there are charitable organizations and drug manufacturer programs that provide disease-related grants to help the patient with out-of-pocket expenses. However, these disease funds are in high demand and become fully funded quickly. For example, when a breast cancer fund opens, it is usually only open for around 2-hours before all of the funding dries up and the fund is closed again. For patients who are fortunate enough to secure disease-based funding, they find that with the high cost of treatment, the grant will usually deplete quickly, and they then have to try to find additional financial assistance.

Factors that determine the route to take for patient financial advocacy:

Diagnosis

There are many disease funds available for patients depending on their diagnosis. The organizations that provide the grants do have income requirements for the applicant and restrict what services they will reimburse. If a patient can obtain funding and depletes the grant balance before treatment is complete, some organizations will only allow them to apply for additional funding every 12 months. This is highly problematic for patients who lack the extra coverage of a Medicare Advantage plan or are without prescription coverage.

Therapy and Treatment

The patient’s cancer diagnosis and staging determine the type of treatments they will be receiving. Depending on the patient’s treatment plan and associated therapies, copay cards are available for these high-dollar specialty medications and infusions drugs. The copay cards are obtained directly from the manufacturer and will help reduce the patient’s out-of-pocket responsibility. There is no income requirement for the application.

Insurance

Patients must have a private or commercial insurance policy for copay card programs. Patients who have government health insurance, such as Medicare and Medicaid, are not eligible for the copay savings programs. Disease funds will also restrict applicants to specific grants depending on what their insurance is.

Copay Accumulators

Insurance companies have started to push back at patients using copay cards by not allow it to count towards their plan out-of-pocket responsibility. Once the patient has used the copay card’s max assistance amount, they are left facing the large unpaid policy deductible.

Patient Income

Patient access programs and disease-based grants have income requirements to qualify for assistance. Some patient assistance foundations clearly define their income eligibility requirements, and some keep the requirements private. Applicants have to fall within the income requirements and proving a certain percentage of the patient’s income is spent on medical expenses. Assistance programs will ask for proof of income, bank statements, and receipts to verify the financial information provided on the application.

How QCSS Can Help

Our years of experience at Q Consulting Support Services give us the knowledge to troubleshoot and strategize how to obtain patient funding through unconventional sources. We proudly help patients, pharmacies, infusion centers, and health systems find the right regardless of income and manage the entire process, from sign-up, appeals, and ongoing charges. We work side-by-side with the patient, their clinicians, and family members and address each of the requirements needed to qualify and receive assistance. This starts with the sign-up process, through to EOB and charge submission, to check or copay collection and ensuring the charges are paid – and submitting appeals in cases where needed.

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