On July 29, the ACCC Financial Advocacy Network hosted an interactive virtual Town Hall: Financial Navigation During the COVID-19 Crisis: Tips from Financial Advocates. Chair Lori Schneider, Oncology Operations Manager at Green Bay Oncology, moderated a panel discussion and Q&A focused on helping financial advocates help patients continue to be able to pay for their cancer treatment during the pandemic.
Panelists began by discussing the accommodations they’ve made to enable their financial advocacy programs to continue during the public health emergency (PHE).
Rifeta Kajdic, Program Manager of the Oncology Service Line at St. Luke’s Cancer Institute in Boise, Idaho, described how St. Luke’s financial navigators are continuing their work during COVID-19. Kajdic said she has adapted St. Luke’s financial navigation workflow to accommodate the changes wrought by the pandemic. St. Luke’s IT department has given Kajdic’s financial navigators remote access to the materials they need, allowing staff to use their computers at home, continue receiving faxes, and make secure phone calls. Kajdic’s team rotates going physically into the office, so one financial navigator is on site each day, acting as a “switchboard” to field incoming requests and triage patient needs. Other on-site staff assist the navigator with communication and paperwork.
Helping the Newly Unemployed
Panelist Angie Santiago, CRCS—the Lead Financial Counselor for Oncology at Sidney Kimmel Cancer Center in Philadelphia, Pennsylvania—said patients who have lost their jobs as a result of the pandemic are adding to the demand for financial advocacy services. Santiago shared her tips for assisting patients who have lost insurance coverage previously provided by their employer. To identify additional financial assistance during this time, Santiago recommended checking fund sources daily, as one that is closed today may be open tomorrow. She also urged all staff—not just financial advocates—to be proactive in asking patients if they have or anticipate having interruptions in insurance coverage. Santiago said financial advocates should move quickly upon learning of a patient’s insurance loss, reviewing that patient’s options and determining the best coverage available to them.
Santiago added that staff should not always assume that COBRA is the best option for newly unemployed patients. If a patient can only afford COBRA for a few months, she said, they may not have the option to switch to an ACA plan afterward. It’s best, said Santiago, to fully vet all of a patient’s options first.
Q&A
Some participant questions asked during the webcast included:
Are unemployment benefits included in adjusted gross income calculations?
Kajdic: This can vary by state. Triage Cancer’s COVID-19 resources explain the federal rules about how new unemployment benefits and economic impact payments can impact Medicaid, Marketplace financial assistance, and other government benefit programs like housing, SNAP, etc. Triage Cancer also has a comprehensive source of information about state laws.
Should patients on an ACA plan who receive the additional $600 in unemployment benefits report that payment to their plan?
Kajdic: We encourage patients to report this additional money to their plan up front in order to be transparent.
How do you choose which insurance programs to include on a comparison grid for patients?
Santiago: Because we don't want it to seem like we're advocating for one insurance over another, we include all available plans in comparison grids. For example, if there are 14 Blue Cross plans, we’ll list all 14, because you never want patients to feel like their healthcare system influenced them to select a particular plan.
When looking at insurance options, should we add up the annual premium and out-of-pocket maximum to get the annual maximum financial responsibility for the patient?
Santiago: We do this based on the insurance plan. If the plan says that chemotherapy is covered at 100%, we’ll tell patients they may not necessarily meet their out-of-pocket maximum. However, if they’re in active treatment and have co-insurance, it’s easier for them to meet that maximum dollar amount. It depends on the policy, but we honestly don’t see many [plans] that fully cover chemo.
Do your financial advocates help patients find marketplace plans if their income is above the guidelines for the ACA, Medicaid, and the facility’s charity plans?
Kajdic: Yes, absolutely. The financial advocates at our site are also enrollment counselors and attend annual training. We will sit down with patients and walk them through the plans on the ACA Marketplace to show them their options, because it can be confusing.
How do you prep your team to be ready for open enrollment? How do you fit that into already-busy schedules?
Santiago: We do our own “advertising” for Medicaid and ACA open enrollment, including putting signage around the cancer center. “Call the Financial Advocacy team if you have any questions or concerns!” We set up time with patients. It’s not face-to-face right now, but I would email them a spreadsheet showing their plan options and walk them through it. We don’t want patients to feel alone or have doubts about their decision. We want them to know we’re still here to support them and we’re still setting up time with them.
Kajdic: The beauty of this role is that everyone really wants to help people. We even help with after-hours enrollment fairs in the community. If we can do something for the community, it will help us down the line to find solutions for our patients.
Do you have a financial clearance process for patients who are starting treatment?
Santiago: We don’t do financial clearance ahead of time or collect money up-front—we don’t want to scare our patients off. On my financial navigation team, we work off our own referrals and who is newly scheduled at the infusion center. We use Epic; our doctors put in the orders and it hits a work queue for our billing and authorization team. That team reviews for medical necessity and obtains authorization. Once the Epic referral is authorized, it hits a work queue for our schedulers, who will place that patient on the infusion schedule. Once we see that there is a patient newly scheduled at the infusion center, we start looking at their medical insurance, out-of-pocket costs related to the treatment, and for any opportunities for foundation support or manufacturer co-pay cards. We also take a peek at the back-end billing. Maybe they’ve met their out-of-pocket maximum, but it’s due to hospital inpatient stays.
Then we go to the patient and introduce our role as part of the support team. We go over their insurance benefits, letting them know if there are opportunities for financial assistance through foundations or co-pay cards, and we assess them for our hospital’s compassionate care program. We also remind patients that we aren’t bill collectors, and we’re here to be a resource to them. If there are no foundation grants open or co-pay cards available, we work hand-in-hand with our social work team to find ways to help with rent, mortgage, or other daily expenses.
So, we aren’t doing financial clearance to indicate that they’re able to pay or want to pay. We’ll set them up on a payment plan and work closely with social work. We want to support patients, and we also don’t want them to share with their family and friends that we’re more concerned about money than their treatment. We are more concerned with making sure they are able to come in for their treatment every time they need it.
Do you have a set timeframe when you meet with patients for an initial consult? Do you meet with all patients or is it dependent upon need?
Kajdic: While we’d like to meet with every patient, we are outnumbered and can’t handle that workload with our team. We rely on our teammates to refer patients to us, such as social workers, providers, and front-desk staff. We let providers know the patient would benefit from seeing a financial advocate. If we need to prioritize which patients we proactively meet with up front, we can go back and review other patients at a later point or find other ways to communicate our services, such as sending a brochure in the mail.
When we do initial meet-and-greets with patients, they might not have questions at first, but they might later down the road. Financial health literacy is a real challenge, and patients may not understand their insurance. We give them a roadmap of what their treatment costs are going to look like so we can take away some of that stress and fear. We let them know they don’t need an appointment to see us.
We also rely on treatment regimens as a back-up screening opportunity. After a provider selects a treatment (e.g., radiation, oral chemo, etc.), it will go to the financial advocate’s workflow, where we can check if the patient is eligible for financial assistance/co-pay cards, and it gives us another opportunity to screen that patient. Similarly, if a patient’s disease is progressing and they suddenly have a new treatment regimen, their financial situation may change. Perhaps they didn’t need assistance two months ago, but now they need long-term disability. At that point, we can contact them again.
Do you have suggestions on how to begin developing co-pay assistance processes in an organization—especially now when a lot of healthcare institutions have suffered financial loss?
Kajdic: Now is the time to capitalize on anything you can do to financially support your patients and your health system. You have to really start tracking your work to arrive at a return-on-investment (ROI) on how these manufacturer co-pay cards, foundation programs, and different assistance channels can help your patient and how your system cares for your patient. If the patient cannot afford their pills, they cannot adhere to therapy. Tracking the impact of your work helps communicate an ROI to leadership on why these programs are important.
Shared resources for financial navigators/advocates:
If you missed this town hall and would like to view it, a replay will soon be available.
