Having trouble getting new therapies covered?
CM offers tips to help you advocate for patients
One hospital-based case manager has had some success receiving reimbursement for high-tech therapies, including Gliadel wafers (see story, p. 174). Whether you work for a provider or payer, Jean Rupert, MS, RN, CCRN, CNRN, the neuroscience clinical case manager at the Wallace-Kettering Neuroscience Institute in Dayton, OH, suggests you try the steps outlined here to advocate for your patients.
• Identify patients who are candidates for high-tech/high-cost therapies early. "The earlier in the process you start, the more likely you are to have high-cost therapies covered," Rupert says. In her setting, she checks surgery schedules, emergency department admissions, and the daily census to identify patients scheduled to receive expensive therapies. "I also keep close contact with our neurosurgeons’ office staff. Now, the surgeons’ staffs often call me to get involved early with their Gliadel wafer patients."
• Inform patients and families about covered benefits. "Patients and families need to know what their insurance covers. I tell them that I think I can help them obtain coverage, but I also present them with treatment alternatives," says Rupert.
• Know the costs and benefits of all available treatment options. "You must be prepared to discuss the comparative costs and the proven benefits of both traditional therapies and new therapies," she notes. "If I’m trying to get coverage for Gliadel wafers, I m ready with the figures and the research data."
• Bring in key people, if necessary. Whether you work for a payer and your medical director doesn’t seem likely to approve an expensive new therapy, or you work for a hospital and that same medical director is denying your reimbursement, enlist the help of your patient’s surgeon, Rupert suggests. "Physicians can help you negotiate with that payer’s medical director. First, fax the medical director every article and other relevant resource at your disposal. If that fails, try peer-to-peer communication between your patient’s physician and the medical director."
• Develop negotiating skills. Rupert suggests getting comfortable with the phrase "outside the scheduled payment." "If you know the therapy you’re trying to get reimbursed is not a covered benefit of the patient’s contract, work with the other party to negotiate a win-win situation," she says. "We had one patient who only used three wafers out of a $9,600 eight-wafer box of Gliadel. We usually charge the patient for the entire box, but because the wafers can be refrozen and used for another patient, we negotiating a per-wafer charge, and the payer reimbursed us for the therapy."
• Always end with a plan. "Whether you’re talking over the phone or in person, never leave without a plan," she says. "Are they going to send you an invoice? Are you going to send them more data?"
• Leave the door open. "Stay in touch with the person you’re negotiating with," says Rupert, adding that case managers should always make sure they ask for and write down the name of the person with whom they are negotiating. "Don’t forget to follow-up with that same person. Don’t ever assume something is going to happen. You must keep checking back."
• Document phone calls with dates and times. "It’s easy to think you’re never going to get a new therapy covered for your patient," she explains. "My first Gliadel wafer case took me nine months, but the reimbursement did come. Don’t ever give up."
Remember, the health care therapies you are advocating may be the technologies you will be using yourself in the future, adds Alan J. Hamilton, MD, head of the department of surgery and chief of the division of neurosurgery at the University of Arizona Health Sciences Center in Tucson.
"Case managers must advocate for their patients. I tell my medical students and residents that the idea of becoming a physician is to learn to love a perfect stranger perfectly. That means you want them to have what you would want for yourself. That’s advocacy. That’s case management," he says.
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