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CBI 2017 Coupon & Copay: Mapping the Copay Journey in Pharmacy and Medical Benefit Settings
- 1. Mapping the Copay Journey in Pharmacy and Medical Benefit Settings Melissa Paige Darrah Seawell 5th Annual COUPON and COPAY
- 2. Talking Points • Current issues and pain points seen within a large academic center • Finding access and managing out-of- pocket barriers to copay assistance programs • Understand the process once a patient enrolls in a copay program • What’s working and what’s not from the patient perspective and where improvements could make a big impact Disclaimer: The views and opinions expressed are those of the author and do not necessarily reflect those of UVA.
- 3. Manufacturer Healthcare Provider Patient Overcoming Barriers Streamline from Manufacturer to Patient
- 4. • Nurses – Everything sent to PA – Different Hubs • Multiple Clinics • Loose Interaction with Billing Department – No Follow Up • Inconsistent Process – Inconsistent Results Large Academic Center Everyone is trying to help
- 5. Patient Physician Nurse Coordinators Financial Counselor Patient Assistance/ Advocate Pharmacy Infusion Pharmacy • Right; Drug, Patient, Time – OOP – Documentation – Procurement – Billing • Claims – Payment – Misc Codes – Revenue Cycle Challenges Large Academic Center
- 6. • Close Interaction – Pharmacy – Financial Coordinators/Billing • Not – Clinic – Nurses Large Academic Center Where should Coupon & Copay Live
- 7. • Time Consuming for HCP’s – Manual Process • Portals – NPI vs Facility Tax ID – Multiple Notifications • Payment to Account Coupon & Copay Some resistance from HCP
- 8. • Website Navigation – FRM Training • How to get Coupon or Copay Assistance – Enroll - Portal – PDF - Fax • How to use the benefits • How to get a claim paid – Either on Medical or Pharmacy Benefits Finding Access Three Clicks or Less
- 9. • All Infusion Product Copay Programs need – Pharmacy Billing Info – Medical Billing Info • Some Infusion Brands Copay Assistance is not set up to be utilized through pharmacy benefits Coupon & Copay Pharmacy vs. Medical Benefits
- 10. • Patient exhausting Insurance Max Benefits • Patient exhausting Copay Card Max Benefits • Day 31 Coupon & Copay Pharmacy Benefit Pain Points
- 11. • Expensive Specialty Drug • High patient out-of-pocket copay • Copay card approved • Insurance max benefits reached • Copay max benefits reached • Now patient has to pay full price for all other Rx • Total Care of the Patient Case Study 1 Pharmacy Benefit Copay Assistance
- 12. Coupon & Copay Medical Benefit Reimbursement Reimbursement Bundled Payments • Have a process to still be able to pay on these claims • Pt starts treatment based on Copay Assistance Submission Portals • High % of claims rejected when faxed. (Not legible) • High % of claims approved the first time when uploaded. Challenges Faxed Claim • Need Notification • When received • Approved or Denied
- 13. • Marketing Materials • Patients given option to receive check or card • 3rd party copay vendors being educated on what to look for – J-Code, does not spell out drug name – No EOB that we have run across yet that has a J-Code and the drug name on it. Coupon & Copay Medical Benefit Pain Points
- 14. • Medical Benefits mandating to use Pharmacy • Coupon & Copay follow the Medication • Impact on Medical Deductible and Yearly Out of pocket • Manufacturer having options to help with Infusion costs Case Study 2 Medical Benefit Copay Assistance
- 15. • Not Working – Required to have physical card before enrollment – Manufacturer requires patient to enroll Working & Not Working Coupon & Copay Programs • Working – Instant online portal/web enrollment – Consistent manufacturer engagement
- 16. • Manufacturer Representative Meet with Account – Oral/Infused – Misc. J-code/Revenue Code – Bundle Billing • Follow-up meeting with HCP Account – Pharmacy/Patient Assistance Department – Financial Coordinators – Billing Department • Determine how to fold into existing process Coupon & Copay Recommendations
- 17. • Copay Portal – Field Reimbursement Education – Beta Test • Copay Card – Payment to the HCP • Portal setup – HCP, make easy (list of NPIs) Coupon & Copay Recommendations
- 18. • Make it easy for HCP to re-verify patients – Comprehensive list of all patients enrolled • Portal • FRM • Current State – Email – Fax – Phone Infusion Re-Verification Re-Verification
- 19. • Satisfaction • Adherence Goals Patient • On Treatment • Payment HCP
- 20. Melissa Paige mlp3w@virgina.edu 434-243-3383 Darrah Seawell dls5pt@virginia.edu 434-243-3868 “To provide excellence, innovation and superlative quality in the care of patients”
Editor's Notes
- It’s fine to have a multipronged approach but I want run it electronically.