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The Pharmacy Reimbursement Specialist

TOP - June 2011, Vol 4, No 4 - Practical Issues for Pharmacists

With the ever-increasing cost of oncology drugs as well as patient copays, a new role was created to help patients manage their financial needs at the Southwest Cancer Center, in cooperation with the Central Pharmacy, University Medical Center, Lubbock, Texas, the county’s and Texas Tech University’s primary teaching hospital. The pharmacy reimbursement specialist works with unfunded/self-pay patients, locally funded patients, Medicare with Part D patients, insured patients offered some chemotherapy by their insurance but denied the best new therapies for their cancer, and insured patients whose insurance will pay for the therapy they need but who cannot themselves handle the expense of the copay ($10,000 per month for some oral chemotherapy agents).

This specialist, Michelle Prieto Flores, spends upward of 80% of her time on the telephone, talking with drug manufacturers, dealing with specialty pharmacies, and systematically following the required procedures for enrollment in patient-assistance programs. Typically, the process of securing needed medications is initiated when a physician orders chemotherapy or supportive treatments, then the pathway becomes more complex, branching off based on the specific cancer and then into intravenous or oral agents. From there, the pathway diverges again, dependent on into which payment group the patient falls. Over time, the establishment of points of contact with manufacturers and pharmacies will help move the process along.

Most manufacturers offer patientassistance programs, and the reimbursement specialist is familiar with them all. Many not-for-profit organizations offer these programs as well. In addition, certain specialty pharmacies can be helpful, often finding a patient-assistance program or foundation for a patient. This work creates a network of “care” for oncology patients that transcends geographic location to try to ensure that each patient receives the treatment he or she needs.

Finding the right program for the patient, however, is only the beginning. The reimbursement specialist’s next step is providing medical forms. Often, this leads to completing the forms with/for the patient. For patients confronted by anxiety about their condition and what lies ahead, sometimes with added difficulties due to lack of education, low socioeconomic status, or language difficulties, the burden of medical paperwork can be overwhelming. By removing this burden, the reimbursement specialist can make the difference between a patient seeking appropriate treatment or giving up.

The pharmacy reimbursement specialist is a key member of the interdisciplinary teams that are required to meet current standards of care in oncology, particularly with patients who endure diseases that require expensive and/or extensive medications. Delivering the finest and most comprehensive care is ultimately best practice on a healthcare level, a business level, an ethical level, and a human level.


Why One Woman Became an Oncology Pharmacy Reimbursement Specialist

“One More Day”
Michelle Prieto Flores of Lubbock, Texas, had no idea that what seemed like just one temporary phase of her work life would become a passionate professional commitment. During her late teens, Prieto Flores worked with group homes for mentally challenged persons, eventually becoming the manager of one of the homes. She was familiar with medications, having helped family with medication administration for several years. In addition, as a home manager, she frequently needed to pick up medications for residents under her care at the local pharmacy, where she became acquainted with a pharmacist.

Deciding to change jobs, she applied for a position as a pharmacy clerk. She didn’t get the clerk position, but she got a phone call from the pharmacist she knew—a phone call that changed her career path forever. The pharmacist invited Prieto Flores to work for her as a pharmacy technician (which she did), subsequently helping Prieto Flores obtain her pharmacy technician license. When the pharmacist moved to the Central Pharmacy at University Medical Center, Prieto Flores moved with her. Working in the inpatient pharmacy, she learned virtually all aspects of the pharmacy.

The pharmacy director saw Prieto Flores’s potential and asked her to take a new position, that of a Pharmacy Reimbursement Specialist. Her new role was to work with both unfunded/self-pay and county-funded oncology patients to try to secure needed medications. Although Prieto Flores still had her office in Central Pharmacy, much of her work moved to the Southwest Cancer Center (SCC). The position grew as the hematology/oncology patient base grew. As the SCC added clinics, physicians, and services, Prieto Flores was in demand. Within a couple of years, she was asked to work directly in the SCC a few days per week, and finally a full-time position was created for her. Administrators, physicians, extenders, and nurses appreciated the value in having this position staffed full time. Once again, Prieto Flores grew her position, both because of the increasing complexity of her job and because she was good at answering the requests of the physicians and meeting the needs of the patients, always with warmth and her characteristic smile. As she is quick to say, “At the end of the day, it’s for the patient.”

When Michelle comes into a clinic room, there is an immediate sense that she is there to help. She doesn’t promise miracles, but rather she says, “The only promise I make is that I’ll give it all I’ve got,” which is quite a lot. Her dedication is important, because the world of medications and the patients who she serves have grown steadily since she began. The advent of oral chemotherapies changed the terrain, as did the development of Medicare Part D.

So what does her job look like now? She now works with a diverse group of patients who have a diverse set of needs, and her aim is to “treat everyone as if he or she was a member of my family.”

What keeps someone doing a tough job, day after day, hassle after hassle, form after form? The answer Prieto Flores gave was “I love what I do.” She also gave another answer, without necessarily even knowing it may be the primary motivation for her. She said that she goes home from work with gratitude for being allowed to spend just “one more day” with her loved ones. Some people don’t get that chance. The opportunity to have “just one more day” may be what causes patients to struggle with difficult chemotherapy regimens and sometimes debilitating radiation treatments. Outsiders and even insiders to the oncology world sometimes wonder why patients hang on to hope and treatment, even when the treatment is not working. Perhaps the answer is “just one more day with my loved ones.” And Prieto Flores does as much as she can to help as many patients as she can get “just one more day.”

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Last modified: July 22, 2021