For many who are stricken with an illness, chronic or acute, it is a time of uncertainty, confusion, and fear about what is happening and without any sense of being able to take control of their fate medically or financially as a result of their condition. The financial uncertainty tagged to the necessary care alone can lead to possible implications over continuity of care and potentially influence patient or provider decisions on the course of treatments that are available.

As a Patient Advocate, you have the ability to instill the confidence that the medical decisions/treatment made between the patient and the medical care team are accessible and leave little to no financial impact for the patient and their family to agonize over. Building trust early in the patient’s journey can be key to developing a strong rapport and instilling confidence that, with your help, allows their primary focus to be about feeling better.

Let’s take a walk with a patient on their journey toward treatment, post-clinical discovery, and discussion. How do you prepare for the conversation with the patient to discuss the next steps to getting them started on their prescribed therapy? Likely, this begins in the days leading up to that meeting between the patient and clinician. In fact, a tremendous amount of information may already be available to you through the funnel of medical documentation that brought that patient into your office. A referral through an HMO, pre-visit labs, imaging, or receipt of a patient’s health record are all examples of information that help prepare you for the steps ahead. A pre-visit benefit check will reveal so much about the options that may be available for you to help support your new patient’s journey. Asking that extra question of “do you have any coverage through family, spouse, or were you ever in the military” can also provide an additional level of coverage once plans are coordinated.

If your patient is uninsured

- knowing the variety of potential resources available is crucial. Being proactive in connecting the patient to available resources can reduce treatment delays. Maintaining familiarity with the process for a patient to follow to enroll in Medicaid or apply for Social Security Disability benefits can be helpful and reviewing your office’s procedure for reverifying eligibility on a monthly basis is important to minimize coverage gaps that result in patient liability for treatment costs. Additionally, staying current with the pharmaceutical manufacturer programs that support patients who are uninsured or under-insured can minimize delays in treatment due to application and approval lag times.

Educating your patient on their own responsibilities in communicating on their own behalf with these programs is essential. In some instances, even non-specific drug rebate cards can be utilized for pharmacy dispensed medications and provide savings to the un-insured (or fully-insured) patient. If your patient is at risk of becoming uninsured, all of the above applies, and with early communication with your patient about their coverage status, you may be able to minimize any treatment interruptions while these options are explored. One of the last stops to look at to help your un-insured patients are the local charities and non-profits who provide assistance for many of the peripheral costs associated with medical illness, like transportation needs, support for utility bills, nutrition, and so much more.

An insured patient, either commercially-funded or through a government-funded plan raises the stakes for you to solidify the processes you and your colleagues share in your practice. Although there are some common steps we take between an insured and uninsured patient, like checking for coverage early and often, there are some distinct differences and considerations a Patient Advocate should be aware of when supporting patients. Let’s examine  the process for both the commercially insured and for government-insured patients:

Your commercially-insured patient

- is most likely to have benefits that run on a calendar year timeframe, but be vigilant for employer groups who have the plans run on a benefit year. Communication with your patient about the plan’s deductible phase and maximum out-of-pocket will help them understand the methods you are taking to mitigate cost-related concerns for them related to their treatment.

A firm understanding of the most commonly prescribed treatments by your doctors is helpful in taking a proactive posture following the patient consultation with the care team. The indications, contraindications, dosing frequency, method of administration are all vital to getting patients approved for a treatment and sustaining treatment through the approval process of the patient’s insurance carrier. By exercising your advanced knowledge of your payer landscape and the treatments being planned, you are prepared for the daily clinical meetings and for patient consultations as they occur throughout each day.

What financial assistance options are available for commercially-insured patients? Manufacturer rebate programs are generally at the top of the list when we think about commercially funded health plans. These programs are generally structured similarly, but each carries its own unique maximum benefit to be redeemed and the process for redemption can differ as well. Stay informed about each individual manufacturer guidelines for copay application/approval/and renewal process along with what their “look-back” policy is. At the heart of the manufacturer copay rebate option is the responsibility for the patient to be informed and in control of this patient-driven program.

There are also potential copay/co-insurance relief options available through independent-charitable groups that offer financial assistance in the form of a grant that patients can apply for based on disease/condition. An important consideration for commercially-insured patients is seeking this option as a secondary alternative following the use of a manufacturer’s copay rebate program, as other patients who have government-funded insurance plans are prohibited from the use of any manufacturer copay rebate program. Please note that funding is not guaranteed and can be limited for certain classes of affliction. Using tools such as PAN FundFinder can be helpful in locating open funding avenues for assistance. Again, it is important to communicate with your patients that they will need to play an active part in the application process and manage this pathway themselves or with the support of the person authorized to speak on their behalf.

For patients with government insurance

– the pathways for financial support are narrowed but not gone. Given what was shared above, patients who have Medicare, Medicare Advantage, Medicaid, Tricare, Veteran’s, etc. plans are excluded from using any form of the manufacturer rebate program and must rely on funding from charitable groups. Medicare patients should be aware (even reminded) of when the open enrollment windows are available for them to make changes. Sometimes, a patient may qualify to become “dually-eligible” for both Medicare and Medicaid, opening up the possibility for added savings. Familiarizing yourself with the CMS website can prove useful in providing education to patients who may not fully understand how their health plan is working for them and to be informed when they need to make changes. Although through the CMS website is information on locating the nearest State Health Insurance Assistance Program counselor who can serve as an unbiased educator to help seniors make informed choices and answer questions beyond the scope of what can happen in the office. Utilizing the “Extra Help” program (formerly known as the Low-Income Subsidy program) may also help patients who meet the financial guidelines.

Your role in the patient’s journey toward an improved health outcome begins early and of a methodical approach, hallmarked in the relentless pursuit to find the appropriate solution in getting a patient started on therapy and ensuring they stay on course. Being their champion, flashlight in the dark, and source of reassurance is a valuable supplement to the medical care being rendered.

 - Cinnamon Solem & Darren Jensen