By providing analysis, education, training, and troubleshooting, specialized reimbursement experts can help prescribers overcome complex administrative challenges, reduce coverage denials, and speed patient access to therapy. Inherently scalable, a field reimbursement program provides a mix of virtual, phone-based and in-person support, according to the evolving needs of the brand.
One of the hallmarks of today’s high-cost specialty medications is that they have complex — often daunting — reimbursement processes, protocols and restrictions associated with them. Specialty medications are particularly costly, and many have both complex administration protocols (involving injection, self-injection or intravenous infusion). As a result, the medical, payer and pharmaceutical communities routinely specify explicit, drug-specific prescribing and reimbursement criteria that must be observed by prescribers. The goal is to ensure that only those patients for whom the medication is most clinically appropriate (following on-label prescribing restrictions) are able to get on therapy.
Rigorous Prior Authorization (PA) requirements and step therapy protocols that aim to restrict prescribing practices, coupled with complex enrollment and claims forms, create numerous hurdles for prescribers. Today’s brand teams are taking a more proactive role in helping prescribers and patients overcome reimbursement-related obstacles.
More recently, the list of medications facing increased levels of reimbursement scrutiny and related barriers to access continues to grow. And the list doesn’t just include classic specialty medications, but a growing list of “specialty-lite” medications, as well. There is an emergence of products that occupy the middle ground between the most expensive specialty category drugs and traditional retail pharmacy that can require a higher level of service support. Transition in the product space requires transformation in the service mix, with collaboration as the guiding premise for all stakeholders involved.
When prescribing therapies within the broad specialty medication category, the impact of logistical and administrative hurdles on physicians (both primary care physicians and specialists) is undeniable, taking time away from patient care and creating barriers that may consciously or sub-consciously influence prescribing behavior. Errors, omissions and delays in reimbursement-related paperwork can create administrative burdens, frustration and inefficiency for the prescriber and his or her staff.
This is especially challenging for practices that rely on the buy-and-bill model for the costly specialty medications they prescribe, and administrators in the clinical setting (as discussed below).
When these challenges remain unresolved, the physician may be more likely to turn away from the brand and prescribe a different therapeutic alternative instead. This impacts both the patient (as the physician is forced to abandon the therapy option that he or she had first thought was the best option), and the brand, by reducing sales and market share.
Today, it is common practice for most specialty medications to maintain a centralized hub platform, and for many high-cost specialty medications, the brand team deploys a team of field reimbursement specialists who provide regular visits to sites of care. As a more cost-effective alternative, Triplefin offers brand teams the Hub-Lite® model, which provides a single point of access for all stakeholders to access clinical and product information.
The flexibility of the Hub-Lite® platform allows the brand team to deploy a more cost-competitive, virtual, phone-based option to support reimbursement issues among patients and providers. Such program design uses highly skilled, regional field reimbursement experts, who provide most of their support using phone-based interactions with prescribers and their staffs. When requested, field reimbursement experts are also able to visit physician offices and hospitals for onsite support.
The ability to integrate a Field Reimbursement support function into this centralized Hub-Lite® structure provides yet another level of critical support for users of today’s complex specialty brands. This benefits physicians and prescribers, removes barriers to access and reinforces the brand’s objectives in the marketplace.
Depending on the needs of the particular medication, brand teams can customize the offering using a mix of automated tools, access to live phone-based and visits with in-office experts, to ensure the most efficient, most cost-effective type of field reimbursement support. The goal is to help physicians — and office staff and nurse practitioners who are involved in the day-to-day aspects of the reimbursement processes — to understand and manage all of the complex requirements to ensure the most successful experience with the brand.
Field Reimbursement: Two types of support
The specific type of Field Reimbursement support depends in large part on the nature of the drug itself and the needs of the brand team.
1. Type 1: Specialty medications that are dispensed directly to the patient and reimbursed under the patient’s pharmacy benefit (such medications are typically prescribed by the physician and then dispensed and delivered directly to the patient, via one more designated specialty pharmacies). For these products, reimbursement support can often be efficiently and cost-effectively provided using a virtual Field Reimbursement team, which provides mainly phone contact with prescribers and their support staff, reducing the need for the brand to maintain the costly overhead associated with a full-time, dedicated Field Reimbursement staff in the field.
2. Type 2: Medications that are dispensed and administered by physicians in a clinical setting and reimbursed under the patient’s medical benefit (these include specialty drugs that are both prescribed and administered by the physician, in an office, outpatient clinic or hospital setting, using the buy-and-bill model). In this instance, a dedicated Field Reimbursement team typically makes regular and as-needed visits to the office, to provide training, and help with troubleshooting, resubmission of denied claims and analysis of trends.
The centralized goal is to provide the appropriate reimbursement services that can assist with the patient access barriers at launch. The Field Reimbursement expert’s role aids in developing a full understanding of payer coverage policies for physician administered products, buy and bill products and billing with a miscellaneous J-code, along with navigating a specific payer landscape.
The value of a virtual Field Reimbursement team
For products that are covered by the pharmacy benefit and dispensed directly to the patient through one or more specialty pharmacies, field reimbursement support can often be provided by a small team of specially trained reimbursement specialists within the Hub-Lite® platform. “This type of virtual support works very well for brand teams that have a limited budget, or want to test the model and then scale up from there,” says Jill Gilbert, Executive Account Manager for Triplefin. “The virtual Field Reimbursement team can help prescribers get through the many reimbursement-related hurdles associated with the medication — on an as-needed basis — and this ensures that the patient is able to get on therapy as quickly as possible.” Removing barriers to access also ensures that patients are able to benefit from the specific medication that the physician selected, not to a different medication selected because the administrative obstacles presented insurmountable barriers at the point of care.
Boots on the ground
The reimbursement requirements associated with costly specialty medications that are dispensed and administered through the prescribing physician’s buy-and-bill program — such as biologics, oncology medications and others that are typically infused intravenously at the physician’s office or an outpatient clinic, hospital or long-term care facility — are even more complex. As such, the availability of on-site Field Reimbursement specialists, who can make periodic or regular visits to the prescriber’s location to provide staff training or help with troubleshooting, provides great impact for prescribes and patients, and ample value for the brand team. The goal of such hands-on support is to help prescribers and their support staff to truly understand the administrative requirements, to overcome barriers that could impede patient access to the target therapy, and ensure optimal, timely reimbursement of the medication to the provider.
“On-site Field Reimbursement specialists are thoroughly trained in all of the specific reimbursement-related requirements of the product in question, and they understand the processes of the dominant insurance carriers in the region,” says Jaron Dawson, Executive Account Director of Triplefin. And while they often collaborate with the brand’s pharmaceutical field sales team to stay abreast of all clinical and product-related information and remain consistent on program objectives, “on-site Field Reimbursement specialists operate absolutely independently of the field sales team,” he says, adding: “Specifically, the Field Reimbursement team’s role is not to educate prescribers about the relative merits of the therapy over its competitor products; rather, they are on hand strictly to educate prescribers and their support staff once the prescribing decision has already been made.”
“By providing training and support and literally walking through the process with prescribers and their colleagues to review denied claims and correct and resubmit them, as needed, these Field Reimbursement specialists ensure a faster turnaround time for reimbursement for the physician’s office, and the patient gains access to therapy more quickly,” says Dawson. And easing the process for all parties reduce the overall hassle factor — which goes a long way toward fostering brand loyalty among both prescribers and patients.
In terms of the on-site support provided by the Field Reimbursement specialists that are deployed to the field, “when they visit the office regularly and build rapport with the office managers and nurse-practitioners, it adds an extra level of hands-on support and training to remove barriers and obstacles,” says Dawson. “This is especially impactful in practices with large numbers of physicians and high patient volume, and in practices that experience high turnover in the office staffing, or where a new office manager or nurse practitioner may not have experience with the complex requirements of the therapy in question.”
Just another member of the team
“The Field Reimbursement team for any given brand is trained and managed by Triplefin but functions seamlessly within the brand’s Hub-Lite® platform, and thus functions as an integral extension of the pharma team,” says Gilbert.
“Sometimes this type of support happens in terms of ‘one-off’ requests from the physician’s office or patient; other times, the Field Reimbursement team can establish a regular relationship with the provider’s office, so that staff can have regular contact with the reimbursement specialists (by phone or in person) on the team using more of a case-management approach,” says Gilbert. She notes that the Field Reimbursement team often works closely with the brand’s Reimbursement Information and Support Specialists (RISS), and the hub’s electronic benefits verification (eBV) capabilities. With such integrated support available, if it arises that specific patients are having trouble paying for their medication, the RISS team can help them to reduce or even reduce or high out-of-pocket expenses for the therapy, by helping the patient to enroll in a Patient Assistance Program (PAP), or to access a coupon or copay-assistance plans, to help patients cope with rapidly escalating and often untenable copays, co-insurance and deductibles.
Meanwhile, Gilbert says: “From a compliance standpoint, we hold our Field Reimbursement teams, and the RISS experts who provide similar support to patients, to the same compliance and regulatory requirements as the brand team would. “Every conversation is recorded and monitored, and we maintain very clear audit trails for any piece of documentation related to the PA process.”
Putting the program design to work in the field
Having some level of Field Reimbursement team in place for the brand is especially important in the months leading up to and following a new product launch, adds Gilbert, when patients and providers face many barriers to access (in terms of having little understanding of new product’s policies, PA process, paperwork requirements, billing code changes and more).
With the inherently modular nature of Triplefin’s Hub-Lite® platform, the brand team can grow the program over time, adding new levels of service, as needed, as the product needs in the marketplace change. “Pharma companies can scale up or scale down to change the size of the Field Reimbursement team, and move from virtual support (largely managing the queries and relationships over the phone) to in-office specialists (providing more regular, in-person support for training, troubleshooting and support), as the needs of the brand change over time,” says Gilbert. For instance, some brands may choose to deploy a larger Field Reimbursement support staff at the time of launch, and then taper off as the marketplace gains familiarity with the product. Conversely, a different brand may choose to start small but then add staff over time, as needed, as the product gains FDA approval for additional indications that are likely to expand the prescriber base (including potentially new types of medical specialists).
When the brand establishes a Field Reimbursement team to support a given therapy in the marketplace, it also allows for a certain amount of data to be gathered and analyzed, and provided to further refine the level and type of support needed for the specific brand. For instance, “as the brand is able to get more products through the PA process, the Field Reimbursement team can gather data on the most common reasons for denial, and how they may vary from payer to payer,” says Dawson.
Similarly, such regular interactions between the Field Reimbursement support team and medical providers allows them to really hear the frustrations that the medical personnel are having with specific aspects of the therapy or its reimbursement policies, or with specific regional insurers or individual specialty pharmacies associated with the drug. Similarly, “while patient-specific information is always de-identified, these interactions allow us to spot a trend spot,” says Gilbert, adding: “For instance, when the Field Reimbursement team notices that a given practice has experienced, say, 25 denials from a given insurance carrier when they’ve never had a problem like that before, this invaluable insight related to trends in coverage determinations can and should be communicated back up the channel to the brand team, so they can investigate.”
“Having eyes and ears on the street, through direct interactions with many office settings, brings value to the process and allows our Field Reimbursement specialists to not only continue to improve their approach, but offer higher touch customer service that many caregivers and patients have come to appreciate.” Dawson adds.