Navigating the Maze of Patient Assistance

  Patients receiving care in an outpatient wound center often present challenges that go beyond the scope of our clinical skills. Today’s economic climate finds us caring for more patients who are either non-insured, under-insured, or on a managed plan that requires authorization and justification for many of the procedures that we do, devices that we use, or medications that we may prescribe.

  We clearly don’t want to compromise on the level of care for this population or any of our patients. We weigh the need for advanced technology, clinical expertise and man-hours against economic pressures on a daily basis. There are certain basic aspects of care that are integral to arriving at a safe diagnosis. These may include imaging, lab work, pathology, cultures and other tests, sometimes resulting in the need for IV access and expensive antibiotics. Past these basic needs, intervening with support surfaces, equipment, and advanced care modalities early on will most often result in a reduced time to healing, which in the long run will result in lesser costs. Add to this the fact that hospitals are also experiencing economic challenges, which drive the need to carefully manage staffing and overtime, while also working to decrease length of inpatient stays. All of this is just the tip of the iceberg of the dilemma facing our patient population.

  The easy answer would be to write all of our recommendations out and send the patient back to their primary care office to sort through all of their needs and ask them to make it happen. The real answer is that these offices (and that’s assuming that they have a primary care physician) are ill equipped to do this without a maximum amount of help from us anyway, so we may as well find a way do it ourselves. Additionally, the delay in obtaining what we need for these patients only results in delayed healing, and potential increased complications leading to emergency department visits and possible hospital admissions. It results in a vicious cycle. Getting what we need for our patients is not impossible, and the more you jump through the same hoops, the easier it becomes. There will be days that we feel more like social workers than wound clinicians, but the satisfaction that comes with being able to provide the highest level of care for these special needs patients will have its rewards.

  There are two main areas where we find ourselves needing to intervene most often—prior authorization and patient assistance. Prior authorization is essentially proving to the payer that what we need for this patient is reasonable and medically necessary. Patient assistance is when there is no payer, and involves programs provided by the manufacturers of drugs, products, and devices to make access available to patients in need. As you learn to navigate each of these, it is helpful to keep a notebook or files of the steps necessary to refer to with subsequent patients to avoid reinventing the wheel each time.

Key Points to Keep in Mind:

  1. Uninsured does not always equate to no financial resources. There are those individuals that if not covered by an employer or government plan, choose to pay their own medical expenses as they arise, versus paying monthly premiums for insurance. Appearances can be deceiving, so always speak frankly to the patient about what you think they need, and the potential costs involved. No one likes to spend money, but many will if their current or future health is involved. Conversely, we also need to be sensitive to patients who have financial limitations relative to their healthcare and avoid causing them feelings of guilt.

  2. There may be many levels of plans within any one insurance program, and because something is covered on one does not guarantee coverage on another. Finding out coverage information each and every time is an unfortunate necessity, even within the government payers such as Medicare and state Medicaid programs. The actual intermediary may have different interpretations and allowances.

  3. There are companies that offer very helpful reimbursement and authorization programs to assist offices and clinics in obtaining the information and approvals needed. This requires the sharing of protected health information with the program, so should only be accessed with the knowledge of your facility administration and with a secured business agreement in place to avoid violation of HIPPA practices.

Prior Authorization for Procedures

  Prior authorization is the obtaining of permission for just about anything from basic visits to imaging to procedures such as debridement or hyperbaric oxygen. Knowledge of the individual’s insurance plan is necessary to determine if this is required, and over time most centers know the requirements of both their local and national plans commonly seen in their practice. To further drill it down, some plans require that the primary care office submit these requests, in which case we will need to provide the information required, while others allow the specialist that has been authorized to see the patient to submit for subsequent needs.

  Authorizations may often be obtained via the telephone, but many require a form to be filled out and faxed in for review. It’s easy to become frustrated with this person seemingly making a judgment on what we know that the patient needs. But becoming frustrated or angry is pointless … they have criteria required to provide the authorization and we must provide the information that will demonstrate that the criteria is met. It is important to ask for a name and a reference number for each telephone encounter in the event that a follow-up call is required.

  Whether dealing with the primary care office or the insurance company directly, provision of the codes relating to both the diagnosis and procedure will be required. Procedure codes (CPT®; Current Procedural Terminology) are generally linked to the covered diagnosis (ICD-9) in the payers system. No clinic should be without the most recent ICD-9 and CPT code books to have access to accurate information for this purpose, and keeping a cheat sheet of the most commonly utilized codes is very helpful. For example, if the request is for the patient to have an MRI due to suspected osteomyelitis of the sacrum/coccyx area, providing the CPT code for the MRI, 72917, MRI of pelvis w & w/o contrast, and the ICD-9 Diagnosis code for osteomyelitis (730.05, acute osteomyelitis of the pelvic region and thigh) will be necessary.

Key Points to Keep in Mind:

  1. Generally any authorization given is done with the caveat that it is no guarantee of payment. There may be a request for clinic notes and documentation after the procedure has been performed, and documentation of the diagnosis for which ICD-9 codes were provided must be clear.

  2. If the response from the payer seems to be too good or too bad it may be, and it may be worth another call to verify. There can be differences depending on whom you speak to, again emphasizing the need for obtaining a reference number and name for each telephone encounter.

  3. If calling for coverage information, it is imperative to also get payment information. Just because the codes are supposed to be covered, it doesn’t mean that the patient won’t still have a co-payment of a fixed amount or percentage of the total charge. Also, especially early in the year, it is helpful to ask if the patient has met their out of pocket requirement, as this may also affect what they will be responsible for financially.

  Some procedures, even though considered to be covered codes, may still require medical review by the payer. It may require the submission of clinical notes leading to the diagnosis and need for the procedure, and/or a written letter of medical necessity. Letters of medical necessity need to be a concise, honest appraisal of the patient condition, and the medical justification for the procedure requested. The singular statement that it is medically necessary is not adequate. Because many of these requests are repetitive, it is helpful to keep templates of the basic information required, and add in the specific patient information as the need arises.

Prior Authorization for Medications:

  Prior authorization for medications tends to take a different pathway. Often it is the patient’s pharmacy that notifies of the need for authorization after they attempt to enter the charge to the patient’s insurance plan. Authorization requests are usually by fax, so it is most helpful to write prescriptions on pads that detail the clinic phone and fax number. Many of these authorizations are going to be to Medicare Part D Providers. There is usually a toll free number provided, and the recording gives the opportunity to enter a fax number over the telephone, which instantly generates a fax authorization form.

  The drugs requiring prior authorizations are those that are not listed on the provider’s formulary, and are usually those that are brand specific and in the higher cost range. Of great importance is that it is often very easy to get this authorization, simply by providing the required information. Two examples that require authorization almost 100% of the time are becaplermin and linezolid.

  Because becaplermin is indicated for a specific wound type (diabetic neuropathic foot ulcer), authorization can only be obtained by noting this diagnosis on the prior authorization form. This is pretty straightforward. Sometimes, though, the forms make less sense. It is standard to have a section on the form where you indicate what preferred formulary drugs have been tried and failed. In the case of becaplermin, there are no equivalent drugs. Humorously—though less often now—we would receive responses to prior authorization requests stating that the patient needed to fail other drugs first, but the drugs recommended were often ointments for debridement or treatment of moisture associated skin damage. A sure way to get the requested drug then was to copy the package insert from the formulary drugs, which clearly outlined that they were actually contraindicated in this wound type. That requirement seems to be out of the system now, but we still must frequently list other modalities and treatments that have been tried and failed, and list why they failed.

  Our other example, linezolid—a higher priced oral antibiotic effective against MRSA—also often will require prior authorization since there are less expensive intravenous drugs with the same indication. Success can be realized by filling out the form, attaching a copy of the culture indicating the infection and sensitivity to the drug, and providing information of prior allergic reactions, lack of IV access, and/or why home infusion will create difficulties or put the patient at risk.

  For anything requiring prior authorization: if the reason is valid, documentation exists to support the need and we do our due diligence in providing the necessary information, the majority of the time we will realize success. However, it does require time, patience, and attention.

Patient Assistance Programs

  Patient assistance programs (also may be called indigent care or charity care) are provided by the manufacturers of both drugs and devices to provide for patients who are uninsured and meet the criteria set up by the company. These programs are highly regulated and must meet standards set by the company without compromise. Common themes amongst most programs include:

  1. Limits are set on the income level allowed for patients to qualify. The patient should be informed that most companies providing assistance will require proof of income at some point in the form of either a W-2 or a recent paycheck stub, which shows hourly rate, and be sure they are willing to comply. There have been instances where patients were visiting from out of state and had no access to these documents and yet arrangements could be made, but this is the exception and not the rule. In these select cases documentation is requested from the patient at a later date.

  2. Be prepared to accept the terms that the particular company has in place for patient assistance. There are limits, and it can be frustrating to be unable to help a patient who, for example, may just have a high co-pay, or too high of an income to meet the requirements of the program. On the other hand, for some programs, the mere presence of insurance is not a problem if there is absolute non-coverage for the desired drug or device.

  3. For most programs, the patient must be a citizen of the US.

  4. The requests for this type of service also must be within the manufacturers on-label indications.

  Of the two, drug programs usually can be accomplished a bit faster due often to the more urgent nature of the need. Some national and regional chains of pharmacies and grocery stores that house pharmacies have community programs by which certain common antibiotics and other drugs are either free or have very low co-pays. Doing some research around your area can provide you with this information to advise patients when prescribing drugs on these lists.

  When the decision has been made that the desired equipment or drug is medically necessary for the patient, contact the company and find out the requirements for obtaining the assistance. Often there are specific criteria not only related to income, but wound type, co-morbid conditions, other modalities tried and failed, and the reason for the request. Knowing this up front enables you to be organized in gathering and providing the information to avoid calls back and forth.

  As mentioned previously, the fact that all of this up front information is required prior to the company providing drugs or a device at no charge to the patient is evidence of the regulatory restrictions placed on the manufacturers. For this reason, we must not only beware of well-meaning representatives who want to help us out by providing free goods and supportive product such as off-loading shoes/boots, instruments and the like, we should not put the representatives in an uncomfortable position by asking for them.

  Navigating this maze of prior authorization and patient assistance may now seem more burdensome than ever! But it really isn’t. Like anything, the more you do it, the easier it becomes. Becoming organized in your approach and making the patient an active participant will save time in the long run.

  The question may still remain as to how to know what is available for our patients in need? There is help available, but it can be very different depending on your location. A patient’s church or community group may have funds available for those in need. Other disease specific support groups such as the American Cancer Society, Multiple Sclerosis Foundation or groups for spinal cord injury or spina bifida may be able to help. Finally, a link to another such organization with potential help for amputees is https://www.amputee-coalition.org/fact_sheets/pros_limb_donations.html.

Melodie Blakely, PT, MS, CWS is the Clinical Coordinator for The Wound Healing Center of Osceola Regional Medical Center in Kissimmee, Florida and can be reached at melodie.blakely@healthcare.com. Dot Weir, RN, CWON, CWS is the co-editor of TWC. She can be reached at Dorothy.weir@HCAhealthcare.com

Manufacturer programs are national and information can be obtained either from your local representative; or by going to the specific company website.

As a result of the focus resulting from this article, today’s wound clinic will work in the near future to provide a page on the todayswoundclinic.com to serve as a resource for patient assistance programs.

Manufacturers or anyone interested in providing contact information to share can send it to Jim Calder at jcalder@hmpcommunications.com.