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Proactive Precertification Pays Off

June 3, 2019

This blog is the fourth post in a seven-blog series highlighting the achievements of this year’s ACCC Innovator Award Winners. Join us at the upcoming ACCC 36th National Oncology Conference, Oct. 30 – Nov. 1, 2019, in Orlando, Florida, where the 2019 Innovator Award recipients will present on their pioneering initiatives.

To Suzanne Francart, PharmD, BCPS, it made no sense.

At Lineberger Comprehensive Cancer Center at the University of North Carolina (UNC) Hospitals, the drug revenue cycle was spread out over several different departments, with no one department having complete ownership of it. “With different groups tackling different parts of the revenue cycle in siloes, they didn’t know how they fit into the larger process,” says Dr. Francart, assistant director of UNC’s Medication Assistance Program and Pharmacy Revenue Integrity Team in the Department of Pharmacy at UNC Hospitals.

A substantial portion of Lineberger Comprehensive Cancer Center’s margin depends on ensuring reimbursement for the infusion drugs the cancer center administers, which requires abiding by payer requirements for drug precertification. Dr. Francart believes UNC’s Department of Pharmacy is well-positioned to manage the precertification process from start to finish. “We have the clinical know-how that is increasingly required to obtain precertification for infusion drugs,” says Dr. Francart.

In 2014, the leadership of UNC Hospitals recognized the need for a proactive approval process for infusion drugs. They began requiring that outpatient orders be placed seven days prior to treatment and that payer authorization be obtained before the drugs were dispensed. The Department of Pharmacy took the lead in this effort, and in 2017, it assumed full ownership of the drug precertification process from start to finish. Today, pharmacy staff—including seven certified pharmacy technicians—complete more than 10,000 preauthorizations per year, the majority within 72 hours of when the drug is ordered. The number of denied drug claims at the cancer center has fallen, and, because fewer denied claims are passed on to patients, they are feeling less financial squeeze.

Lineberger Comrehensive Cancer Center's closed-loop, pharmacy-managed, precertification program—and, more recently, its integrated denials management program—has required the Department of Pharmacy to invest in expanding its staff. During the past three years, eight additional staff members have been added, making the revenue team 13 employees strong. In addition to certified pharmacy technicians handling precertifications and enrolling people into patient assistance programs, a nurse, a denials specialist, and a pharmacy revenue integrity pharmacist are also on the team.

“We’ve made an investment in hiring additional employees to help drive this process,” says Dr. Francart. “We provide leadership and training, and we’ve created a dedicated precertification program.” The program has produced results. For example, at Lineberger, medical necessity reviews affect treatments responsible for $2.4 million in annual institutional drug reimbursement. Thus far, treatments undergoing proactive medical necessity review have not been associated with any post-treatment drug revenue loss.

Francart says that because Lineberger Comprehensive Cancer Center is part of a state institution, it serves a large number of uninsured patients. “To be able to afford their care, we have to have a robust system for identifying and enrolling patients into free drug programs sponsored by manufacturers,” says Dr. Francart. “As soon as the orders for an infusion drug are written and a patient is identified as uninsured, we enroll them in these programs. We have committed three full-time employees to this sole function.”

UNC is currently reinforcing the back end of the reimbursement process after infusions are administered, she says. “If a claim is denied, we need to know why, make adjustments to the precertification process, and submit effective appeals,” Dr. Francart says. “We want to eliminate the risk of write-off or passing the bill on to the patient. We are seeing a reduction in our denials rate due to our proactive work and more robust appeals process.” Through the efforts of her team, more than 60 percent of denied claims for medical necessity are overturned on appeal.

During her session at the ACCC 36th National Oncology Conference, Dr. Francart will discuss how keeping different parts of a drug revenue cycle siloed in multiple departments can be inefficient and frustrating, and delve into the ways in which implementing a proactive process for precertification pays off. “There’s a need for a clear ownership process, rather than everyone doing just one piece of the work,” she emphasizes. “The financial implications of even small changes are huge in cancer care, and even small centers can adopt this model.”

Join us at the ACCC 36th  National Oncology Conference in Orlando this fall, where you can learn how a pharmacy-led precertification program can enhance your cancer program’s revenue cycle.