We continue to see the “screws tightening” in healthcare. COVID chaos, delayed screenings, value-based care, a more complex patient, financial difficulty, to alternative payment models, there is much change. Responding to this change must be swift and strategic---mostly different.
There is much attention and focus on “advocates” right now as they are key for patients effectively navigating the system and the system
remaining financially viable. With the backlog of patients, seeking care especially in Oncology and the rules/guidelines changing almost monthly, there is/has been exposure into the lack of effective investment & inefficiencies in this role.
Most importantly it has exposed the importance of this role in mitigating barriers for the patients and expediting their process. The role of the “patient advocate” has proven to be difficult to define, but their impact is significant for the practice, service line, pharma, vendors, and payers.
The first issue for this role is an all-encompassing name. Several are used interchangeably but have different capacities, objectives, and expectations CLICK HERE to see some of the “tasks”.
Some of these names include:
Financial Counselor Financial Navigator Patient Navigator
Patient Advocate Benefits Coordinator Patient Service Representative
Care Coordinator Patient Relations Professional Patient Access Specialist
Authorization Specialist Pre-Certification Coordinator Referral Coordinator
The term “other” on a job description truly captures what they do. From patient intake to prior auth to financial/benefits connection, they cover a wide spectrum that is critical. There is much assumption about this unclearly defined role and how it functions. As an administrator, spending time with these individuals was critical for me to understand what they needed to do their job effectively. From one week with them I saw needs such as:
Minimum Dual Monitor set up Dedicated space / distraction free Fax Server Access
Financial Tools for Estimates EMR/EHR Access to all aspects Empowerment for Decisions
Portal Access Phone connections Remote/home Access to clinical staff
The other barrier that many seem to have is what are the qualifications for an “effective” patient advocate? Let me assure you there is no 4-year degree that can make up for experience in this role. There are far more important traits than a degree that have proved to more valuable for these roles: (yes a baseline is needed).
• Type A personality
• Drive and initiative
• Able to pivot
“We are more of a case manager minus the nursing degree”
There is nothing wrong with a formal education and certification and specific licenses. However, this role is incredibly unique and is often changing based on healthcare/payer rules and guidelines. Organization like www.NAMAPA.org and their Advocate Summit are continuing to put an emphasis on connecting these individuals so the needed standardization and applicable education is available. Work done by ACCC and their financial advocacy arm has also been instrumental in ensuring advocates have resources they need to do their job.
Specialties like proton therapy, have tried to place clinical people in this role for specific tasks like Prior Authorization. This is a limited approach that at scale is not cost effective because prior authorization is on 25% of this role and what is needed for the patient’s needs for the continuum of their care path.
In speaking with departmental directors, the value of these individuals is often not seen until they leave. All to often this become a high turnover position, leading inconsistencies and gaps in effectiveness.
So, what is the big deal with this role, just have someone do the auths and do some follow up. Or just outsource it offshore or if they can do one specialty, they can do them all. No. This is part of the disconnect. For Oncology, the treatments and drugs associate with cancer care can be hundreds of thousands of dollars A typical course of radiation therapy is between $16,000-$25,000. Chemotherapy has a large gap cost interval from Rituxin at about
$10,000 per injection to CAR T-Cell therapy at over $300,000. Financial Toxicity is real, and Advocates mitigate headache. Mitigating this stress improves outcomes and satisfaction. Toxicity Due to these nuances, it’s important to have an advocate that understand your local market. What many people fail to see is that an advocate can act more like a social worker in their everyday functions, but as we can see, the role often entails much more than that.
Knowing how to authorize for these treatments and services is imperative or the patient could be stuck with the balance and/or the facility eat the cost. What about helping the patients find resources for coverage? During COVID, I spoke with several patient advocates who stated it was routine for patients to simply look at the cost and say they would just be sick. They did not know there were co-pay assistance program available to help cover their cost. Insurances were lost in the middle of COVID. What about these patients? What if their insurance change in the middle of a course of therapy—Example from UHC to BCBS? Will there be a gap in treatment? What about a patient that meets the Medicare age requirement during treatment? There are thousands of scenarios, one offs, and caveats. Where are things in the process. These are all things the “patient advocate” is balancing, communicating, and coordinating. Most of the resources available are through pharmaceutical companies and local programs. With each county and state having different financial resources, we see a wide range of the types of programs offered to patients. This is why it’s important to have an advocate that is aware of what their local resources and restrictions are. This trickles down even to Medicaid. For example, in California, each county is responsible for partnering with local contracted health systems to implement it’s Medi-cal program. These contractors determine formularies based on population needs and other important guidelines that effect patients and providers. This is work that simply can not be done by an off shore team if you want your patients to have the best possible outcome.
Many are looking to save money by eliminating positions and scale. This is not an area to do this in. As a matter of fact, this is an are to be proactive and invest in. This role should not be looked at as a cost center, it is a revenue center. The financial implications from these treatments/drugs justify their salary. This is the major issue. Why is it that the people that are ensuring that the providers and facilities are paid properly and there are no financial surprises for the patients, paid so little? Check out some of the pay ranges:
In searching all of the different name titles of the “patient advocate”, the average public data that was available was between $35,000 and
$60,000 per year. This equates to $16.82 to $28.84 per hour. This is a broad range. Based on the procedures that are ensuring that there is coverage for or enrollment into programs, this is definitely on the low end.
Some level of standardization and a voice that is heard will help ensure that there is better compensation alignment. Having extensive turnover at these roles can have an immediate impact on AP for the facilities and the providers. Most importantly it can be the difference in a patient receiving their treatment in a timely manner or at all. Medical bills are reported to be the number one cause of U.S. bankruptcies. One study has claimed that 62.1% of bankruptcies were caused by medical issues.
It’s well known that securing revenue on the front end is easier than trying to recoup monies paid on the back end. A good advocate can be the person that helps keep your doors open and the lights on.
If you want your company to be viable you need someone that is dedicated. Most importantly, there is no training.
The position has been defined by a job description not application, value, or execution
Roles and Responsibilities per Indeed Search
• Demonstrates excellent customer service
• In conjunction with the Medicaid Eligibility Staff visit all uninsured patients in-house
• Provide estimates to patients and/or physicians as requested
• Generate insurance verification and precertification reports daily and follow up with case management and insurance verification departments as appropriate
• Follows all guidelines set forth in the Cash Handling policy
• Utilizes eligibility systems, on-line websites or phone calls to determine insurance benefits and precertification requirements
• Assist patients with payment arrangements and in co-ordination with the Medicaid Eligibility Staff assists patient with financial applications
• Contact patient employer, if necessary, for verification of employment, premium status, babies being added to policies
• Escalates any concerns as needed to Patient Access Manager/Supervisor
• Enter pertinent insurance information into the HIS system (i.e. Meditech)
• Enters appropriate notes for all patient encounters
• Maintain professional image and implement excellent customer service to customers
• Complete financial analysis and collect estimated patient liabilities
• Follow up with patients for necessary signatures if they were incomplete at time of hospitalization
• Attends in-service presentations, and completes mandatory education, including but not limited to, infection control, patient safety, quality improvements, MSDS and OSHA standards
• Demonstrates knowledge of occurrence reporting system and utilizes system to report potential patient safety issues
• Provides customer support by phone, email, or instant message to business customers. Serves as primary contact for inbound/outbound customer issues.
• Processes a high volume of customer inquiries of One Call products and services.
• Troubleshoots customer problems, identifies the root cause of the problem, and uses tools and resources appropriately to determine how to resolve customer problems.
• Follow escalation protocol for unresolved issues that include continual coaching and mentoring to ensure proper escalation follow up.
• Tracks and documents inbound support requests and ensures proper notation of customer problems or issues.
• Updates customer information and ensures accurate entry of contact information.
• Meets the standards of the job, such as quality standards, adherence to schedule, and average handle time.
• May provide guidance and/or mentoring to less experienced Care Coordinators.
• Under limited supervision, performs professional level support. Uses established procedures to perform assigned tasks.
• Serves as a patient advocate in providing assistance/expertise to patients, families and other external or internal contacts.
• Works closely with patients/families and federal, state and county caseworkers to ensure approval of assistance. Screen and assist in completion and submission of applications.
• Work directly with patients, doctor's offices, and hospital departments to gather sufficient information to obtain authorization and benefits collection of patient portion.
• Acts as a liaison between the patients, physicians, patient clinics, case management, centralized billing office, third party Medicaid eligibility vendor and community agencies.
• Screens patients to make the determination of eligibility for internal and external assistant programs.
• Actively participates in public presentations, county hearings, case review meetings, committees, and task forces.
• Performs advanced and/or complex duties requiring independent decisions and extensive, diversified professional experience and knowledge.
• Performs other duties and responsibilities as assigned.
• Provides intake services and setup for all new patients
• Coordinates the patient's care with physician offices nurses pharmacists and patients.
• Performs insurance verification both major medical and pharmacy benefits.
• Coordinates prescription deliveries and refills for patients.
• Works with home health nursing visits and maintenance of a patient census throughout the course of their therapy.
• Supports other team members in the healthcare team.
• Ensures a continuous quality improvement customer service approach by proactively identifying areas of improvement and communicating those ideas to the healthcare team.
• Maintains current documentation related to the patients drug therapy and pharmacy care plan. Flag issues that need to be addressed.
• Coordinates responses and resolutions to issues with appropriate internal and external parties.
• Actively participates in roundtable discussions with Pharmacists Nursing Services and Pharmacy Care Coordinators to review cases and related drug therapy and pharmacy care plan issues.
• Maintains and promotes positive and professional working relationships with associates and management.
• You will perform all components of call processing for inbound and outbound contacts while documenting those calls in the system
• You will receive constructive feedback and coaching
• You will provide superior customer service to internal and external customers and patients
• You will support the vision and strategy of the contact center while positively promoting the services offered and elevating issues to contact center leadership
• Authorizes medical services for patients. Contacts insurance companies via phone or website to ensure that eligibility and benefit information is obtained and authorization is in place when necessary. Documents all contacts in the hospital information system.
• Maintains a balance with regards to the interest of the hospital and the patient situation or concerns when resolving accounts.
• Obtains pre-authorizations/pre-certification per payer requirements for services rendered and ensures authorization information is documented in the appropriately in the system.
• Verifies physician orders are accurate, determines CPT, HCPCS and ICD-10 codes for proper Prior Authorization.
• Ability to understand and communicate insurance co-pays, deductibles, co-insurances, and out of pocket expenses for point of service collections.
• Communication is maintained with providers, clinical staff, and patient in relationship to authorization status.
• Works and assists with the billing department in researching and resolving rejected, incorrectly paid and denied claims as requested.
• Helps to maintain a professional atmosphere for patients, family members and staff.
• Remains current with insurance requirements for pre-authorization and provides education within the departments and clinics on changes.
• Keep management informed of changes in authorization process, insurance policies, billing requirements, rejection or denial codes as they pertain to claim processing and coding.
• Assume leadership role in recommending, implementing and monitoring sound financial counseling guidelines for Radiation Oncology, and Satellite facilities
• Interact with patients and family members (if necessary) in the most courteous, respectful and empathetic manners in discussing all aspects of their financial situation.
• Work with other departments including XRT satellite operations and the multidisciplinary clinics (PASs) to provide patients with the most accurate estimate in an integrated and expeditious manner.
• Strengthen the integrity and confidentiality of patient financial information by sharing that information only for reasons as stipulated by the institutional guidelines.
• Maximize the functionality of various institution and Radiation Oncology information systems software/platforms such as ONE CONNECT and MOSAIQ to accomplish duties promptly; documenting in EPIC for all coverage and financial clearance outcomes to aid in timely claims processing.
• Responsible for complete assurance that patients and family members (if necessary) understand all aspects of their financial relationship with the institution and the Division of Radiation Oncology.
• Assume leadership role in managing patient data update, financial clearance status, and expeditious appointment scheduling.
• Ensure timely, proper and efficient collection of patient demographic information and also update patients' files regularly.
• Following institutional and departmental guidelines, work closely with PASs, New Patient Referral, and XRT satellites to ensure expeditious triaging and scheduling of patients.
• Responsible for ensuring that there is understanding between clinical teams, referring parties and others regarding patient appointments.
• Asserts complete oversight in assuring verification, pre-certification and terms of various insurance plans and benefits.
• Clearly review and manage to established institutional and departmental guidelines to achieve standards for verifying insurance, performing pre-certifications, and assuring insurance updates for all patients.
• Establish functional and productive working relations with third-party payor agencies such as Managed Care Office and outside insurance companies.
• Responsible for interpreting and reviewing regular contract summaries, provisions and restrictions as they apply to various patient population for Radiation Oncology, its outreach and satellite facilities.
• Obtain and document verification of patient eligibility (and applicable effective dates) using the available institutional and/or payor systems, including real-time web portals and tools, within the applicable timeframes as outlined by department policies and procedures. Promptly notify Patient Navigator and the patient, when eligibility information is invalid and/or cannot be verified
• Work collaboratively with Intake team to document updated and/or corrected insurance information into the system in accordance with applicable department policies and procedures
• Obtain and document verification of patient benefits, including information regarding the product type, in-network or out-of-network status, all applicable co-payment, deductible, and co-insurance amounts or percentages, pre-existing indicator and time period, and any lifetime or annual maximums into EPIC and/or designated future state systems in a timely manner
• Timely manage work lists for cases requiring pre-authorization and work directly with the payor or assigned third party vendor to obtain all required pre-authorizations. Seek to obtain pre-authorization through on-line web portals and tools, when available. Accurately document all reference and pre- authorization numbers, along with payor contact information, into EPIC and/or designated future state systems in a timely manner
• For patients participating in a clinical trial, appropriately document and review with patients and the payors services being covered by the clinical trial sponsor and those designated for coverage under the patient's insurance
• Provides financial counseling to patients which includes reviewing cost estimates, assistance with calculating expected patient liability, discussions regarding payment requirements, collection of financial amounts dues, provide information regarding available payment plan options, and provide information regarding patient financial assistance opportunities when applicable. Financial counseling also includes reviewing ABN, MSPQ, account review and any other barriers to financial clearance with patients as needed
• Complete and timely submit all documents (PFA, COBRA, etc,) requiring prior approval for financial clearance.
• Promptly escalate any issues with financial clearance and/or counseling to the Financial Clearance Supervisor or seek assistance as appropriate from the Financial Clearance Center, when needed
• Completely and accurately document conversations and communication with Patients, payors, third party vendors, MCLs and any other representative in and outside of the institution
• Answer emails and phone calls in a timely manner and respond to voicemails and messages within the course of the business day.
• Conducts all financial clearance activities in alignment with departmental key performance indicators to ensure that timelines are met and surpassed.
• Assess your monthly KPIs and work to minimize variation and follow standard workflows to ensure no defects, implement self-improvement actions to be reviewed with your one up.
• ties in a courteous and professional manner and maintains a positive working relationships with patients, physicians, payors, third party vendors and any other identified business partners
• Seeks to improve job performance and personal growth by participating in available educational, training and mentoring opportunities
• Perform all other duties as assigned
Alexis Meza Ann Kline Elizabeth Johnson Melissa Paige
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