Financial Advocates Discuss Challenges in Radiation Oncology

It is no surprise to financial advocates that accessing treatment cost assistance for radiation oncology patients is a major challenge. Unlike its medical oncology counterpart, radiation oncology services are not covered or reimbursed through manufacturer-based assistance programs. In response, ACCC’s Financial Advocacy Network held two small-group coffee chats to assist its members in identifying and addressing barriers to financial support for patients receiving radiation therapy.

While most financial assistance oncology staff can provide patients undergoing radiation treatment comes from their own organization’s internal charity fund, other assistance can be accessed through grants from independent foundations like the American Cancer Society (ACS). The issue: these grants are generally focused on supporting “other” costs like transportation, gas, and housing, not direct treatment costs.

The biggest financial strain these patients face is their medical bill, especially those who are paying out of pocket. Financial advocates will identify other assistance options (e.g., transportation, housing) to free up monies for patients’ medical bill. Further, some states offer programs that help uninsured or underinsured patients cover their treatment costs. But this help is not available nationwide and is specific to certain disease sites, such as breast and cervical cancer. Patients who are paying out of pocket are often left to pursue county-based assistance or Marketplace insurance plans that could have catastrophic financial outcomes.

To better meet patients’ needs, coffee chat participants discussed potential opportunities of financial assistance via radiation oncology device manufacturers, where established funds could support direct treatment costs. The network’s Voice Task force will also connect with independent foundations to discuss potential strategies for developing assistance funds that are accessible to patients undergoing radiation therapy.

Prior Authorizations and Denials

In handling prior authorizations, particularly when there are clinical- or payer-related changes in the middle of patients’ treatment, participants had questions. For example, how should financial advocates address treatment changes when the radiologist adds a “boost” (or more fractions) than was initially planned? What about when a patient does not show up for their treatment appointments and more are added? Participants shared that some cancer programs and practices will not continue patients’ treatment without a prior authorization, but delays in authorization can cause treatment delays.

Participants discussed several ways to ensure care continuity. Some rely on their dosimetrists to help fill out payers’ required prior authorization forms, while others use electronic health record tools to communicate with their prior authorization teams and to ensure thorough documentation. Sometimes financial advocates rely on the radiologist’s direction: that additional treatment is medically necessary and to proceed without a prior authorization. In these scenarios, participants shared that the decision to proceed with treatment falls on them. Therefore, a discussion on who bears financial responsibility would need to take place; either an advance beneficiary notice or non-covered services form needs to be signed by the patient. Failure to obtain these forms can result in lost revenue.

In agreeance, participants discussed that a major challenge they face is frequent payer policy changes. A big pain point is that payers do not allow patients in active treatment to be grandfathered into their original authorization requirements at treatment start, resulting in a new prior authorization requirement. Therefore, it is vital that financial advocates to keep up to date with these changes.

The Radiation Oncology Model

Lastly, coffee chat participants discussed the implications of the Radiation Oncology (RO) Model. They anticipate the model will streamline patients’ treatment. However, increased use of hypofractionation—a treatment schedule where patients’ total radiation dose is split into larger doses, requiring less treatment appointments—may impact productivity numbers and call for staffing re-evaluation. Cancer programs and practices that rely heavily on radiation oncology revenue may struggle, and participants shared that revenue models are indicating the RO Model will be a negative revenue generator.

Participants’ noted that their organizations are doing more brachytherapy than intensity-modulated radiation therapy treatments, and there are fewer patients in active treatment. While the billing process seems overwhelming, participants agreed that there will be implications to financial advocate staffing levels—a group that is struggling with high workloads and lack of extra staff for support—if the model is implemented.

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