Managed care pharmacists, through implementation of a clinical authorization process, can play a pivotal role in securing payer reimbursement of chemotherapy agents at a cancer hospital, according to recent data.
What's more, by developing a clinically staffed chemotherapy authorization department, managed care pharmacists can also help increase the procurement of replacement chemo therapy drugs.
Those conclusions were reported by Shetal S. Desai, PharmD, who was hired 2 years ago as the director of the Clinical Authorization Center at the University of Southern California (USC) Norris Cancer Hospital in Los Angeles.
"My study is actually my job," said Desai, who has worked extensively in managed care. Her job required that she examine the issues surrounding financial reimbursement of chemotherapy drugs. Afterward, she was responsible for implementing procedures that were intended to decrease disputed claims and improve drug replacement through enrollment in pharmaceutical manufacturer–driven programs.
The USC Norris Cancer Hospital is a private, 60-bed research and teaching hospital with an onsite outpatient chemotherapy infusion center that services between 20 and 45 patients daily. The payer mix includes commercial insurers and Medicare.
When Desai was brought onboard, the facility was having problems with payer reimbursement of chemotherapy agents. "In fact, monthly total disputed claims dollars averaged between $600,000 and $1 million," she said.
The hospital administration was unclear about the reasons for unpaid or disputed claims, she added.
Desai, who is also an assistant professor at the USC School of Pharmacy, found:
- The main reasons for disputed or unpaid claims were a lack of authorization before treatment was administered and the use of an agent for unapproved indications
- Bevacizumab was the most commonly used chemotherapy agent and the one most frequently disputed; the main reason why the claims were disputed was that payment was being requested for off-label use of bevacizumab (eg, treating metastatic breast cancer before it had been approved for that indication)
- Roughly 40% of all visits for chemotherapy administration were not scheduled in advance
- Physician chemotherapy orders were not routinely sent to the authorization department prior to a scheduled appointment
- Third-party payers requested from 3 to 5 days to respond to an authorization request
- Authorizations were requested by nonclinical hospital personnel, who did not have the clinical knowledge to be able to respond to clinical questions prospective payers needed answered before authorizing payment
- It was difficult to request payment from payers when authorizations for chemotherapy were not accurately obtained or appropriately documented
- Clinical criteria for authorization varied by payer and coverage plan.
After reporting her results to the hospital administration, Desai recommended that a new clinically staffed chemotherapy authorization department be developed. "A staff that is clinical is crucial, because they can actually speak the language of the insurance companies and they can obtain the proper authorization before treatment," she said. "In addition, they can supply the insurance companies with any peerreviewed journal articles that might provide enough evidence for treatment in unapproved indications."
Ideally, a managed care pharmacist should serve as the director of the authorization department, and nurses with a case-management background should be hired as clinical authorization specialists, Desai observed.
Medical staff, she said, should submit orders 3 to 5 days before treatment to allow sufficient time to obtain authorization.
The authorization department should also determine whether patients being considered for off-label treatments are eligible for pharmaceutical manufacturer–sponsored patient-assistance programs. If an insurance company denies reimbursement because a drug is to be used off-label, the authorization department will contact the company that manufactures the drug to determine whether the patient is eligible for drug replacement through the pharmaceutical manufacturer–sponsored patientassistance programs, she added.
One year after the implementation of a clinical-based authorization center, more than $1.1 million in total drug replacement has been recovered, Desai reported.
Also, claims were processed more rapidly and in some cases on the same day the request was made. There was also a reduction in the number of claims denied due to lack of authorization.
An additional benefit of the new clinically staffed authorization department is improved communication between the authorization department and medical and nursing staff.
Desai was unable to determine the extent of improvement in reimbursement to the hospital for chemotherapy with the new authorization process, because her hospital changed ownership earlier this year and retrospective data thus became unavailable.
"If hospitals want to improve their reimbursement, they need to have a managed care pharmacist in charge of this area," Desai said. "Otherwise you'll have someone who will not know how to get around some of the obstacles the insurance companies put up."