2. TOP 10 CONCERNS FROM OFFICE
STAFF REGARDING NEW DRUGS
• NEW DRUGS ARE BEING PRESENTED TO THE PHYSICANS BY DRUG COMPANIES MORE
AGGRESSIVELY
• PHYSICANS WANT TO USE THE DRUG YESTERDAY
• “HOW DO WE BILL FOR A NEW DRUG?”
• “WHAT CODE DO I USE?”
• “WE HAVE THE DRUG NOW WHAT?”
• “WE WILL NOT GET PAID!”
• “ WHY DID WE RECEIVE A DENIAL?”
• “TOO MUCH HASSLE TO GET THIS CLAIM PAID FOR!”
• “OH WELL, WE WILL WRITE THIS CHARGE OFF, WE ARE A BIG PRACTICE”
• I’LL NEED MORE STAFF TO WORK THE DENIALS
3. PREPARING FOR NEW DRUG
UTILIZATION
• MEET OR CALL DRUG REPRESENTATIVES AND ASK FOR INFORMATION
REGARDING NEW DRUG:
• REQUEST INFORMATION ON THE FOLLOWING:
• MISC CODE
• REIMBURSEMENT ASSISTANCE
• PROVIDER SITE OR PORTAL
• BENEFIT INVESTIGATION
• MEDICARE/MEDICAID APPROVED?
• DENIALS AND APPEALS ASSISTANCE
• DRUG PROVIDED UPFRONT WHILE REIMBURSEMENT PROCESS IS BEING DONE?
4. DRUG EDUCATION PROCESS
• ACCESS DRUG COMPANY’S WEBSITE FOR THE SPECIFIC DRUG YOU ARE USING:
• EXAMPLE DRUG: OPDIVO
DRUG COMPANY: BRISTOL MYERS SQUIBB
UTILIZE BENEFIT INVESTIGATION FORMS…..OBTAIN BILLING CODE INFORMATION…PATIENT
ASSISTANCE
5. DRUG COVERAGE AND BENEFITS
• CHECK NCCN GUIDELINES/MEDICARE/FDA APPROVAL BY DIAGNOSIS
• MEDICARE GUIDELINES (NOVITAS DRUG CODE LOOK UP)
• DRUG POLICY BY CARRIER (EXAMPLE: AETNA POLICY)
• COMPLETE BENEFIT INVESTIGATIONS ON ALL INSURANCE CARRIERS
• (BMS ENROLLMENT FORM)
• PRE-DETERMINATIONS AND AUTHORIZATIONS COMPLETED
• BENEFIT INVESTIGATION RETURNED:
APPROVED
DETAIL GUIDELINES GIVEN FOR REIMBURSEMENT OR DENIAL
APPEALS SUPPORT
6. CLAIM BILLING
FOLLOW DRUG COMPANY GUIDELINES FOR BILLING:
USE J CODES
INCLUDE CPT CODE 96413
NDC CODES FOR EACH UNCLASSIFIED DRUG
ALL CODES NEED TO BE ON HCFA CLAIM FORM
•If the miscellaneous service is a
drug (e.g., J3490), the NDC
number of the drug and dosage
information should be listed on the
claim.
7. TRAINING
• TRAIN STAFF USING PROTOCOL ANALYZER FROM ION SOLUTION
Remove the estimation or guess of drug costs
Find Chemotherapy Treatment plans or pathways
Fee Schedules are attached to analyzer
Analyzer shows cost of drug and reimbursement status for practice
Estimated cost for patient
Printed form for patient to sign for financial responsibility
HANDOUTS: PROTOCOL ANAYLZER DRUG COST AND PATIENT FORM
8. PATIENT ASSISTANCE PROGRAMS
• ENROLL ALL PATIENTS IN COPAY/COINSURANCE PROGRAMS FOR
OOP/DEDUCTIBLES
PRACTICE DOESN’T HAVE TO BILL PATIENT FOR LARGE PERCENTAGES OF
COINSURANCES!
And Yes even if: DED/OOP MET
Enrolling once protects the practice against:
• LOSS OF INSURANCE
• NEW INSURANCE
• NEW YEAR BENEFITS
• NEW EMPLOYEES Eliminate Loss of Revenue
9. APPEALS PROCESS
• REQUEST APPEAL SUPPORT THRU DRUG COMPANY
• HAVE ARTICLES OR DOCUMENTS TO HELP SUPPORT USE OF DRUG.
• PREPARE LETTERS OF MEDICAL NECESSITY
• WORK SMARTER UPFRONT BEFORE CLAIM IS SENT!!!
• OBTAIN BETTER REIMBURSEMENTS WHEN ALL PROCESSES ARE COMPLETED!!
• YOUR STAFF WILL BE SUPER HEROES!!
HANDOUTS: MEDICARE APPEALS
FLOW CHART AND LETTER
10. HELPFUL TOOLS
• CHECK OFF LIST FOR ALL PROCESSES FOR DRUG APPROVAL AND
REIMBURSEMENT
• DRUG COMPANY PROVIDER PORTALS AND/OR ASSIST POINT
DISCUSS HANDOUTS AND OPEN DISCUSSION
I’M HERE TO HELP WITH ANY QUESTIONS OR CONCERNS!
THANK YOU!
