Learning the ROPES: a BEGINNERS GUIDE TO THE TFC PROCESS FROM REFERRAL TO POST TRANSPLANT

1. Learning the ROPES: a BEGINNERS GUIDE TO THE TFC PROCESS FROM REFERRAL TO POST TRANSPLANT Lisa Donovan, Transplant Financial Coordinator, SUNY Upstate university hospital, Syracuse, NY Deidra Simano, Transplant operations analyst, Dartmouth-Hitchcock medical center, lebanon, nh

2. Referral is received in the office • Demographic/ information obtained from referring provider • Insurance authorization for evaluation obtained as needed

3. Referral entered into epic • TFC confirms that we are in network with the insurance, or if out of network, we confirm if patient does have out of network benefits to proceed at our center • TFC creates the Epic episode • TFC enters the referral • TFC creates the pretransplant checklist

4. Benefit verification obtained from insurance carrier • Inpatient benefits • Outpatient benefits • Prescription benefits

5. Patient education session • One morning per week, we offer a patient education session • Each member of the team presents on their own specialty • Patients really seem to like it and feel that they learn quite a bit

6. Evaluation day • Each patient will come in for a full evaluation (outpatient) • This can take a lot of the day • May/may not be the same day as education

7. The financial coordinator will meet with every evaluation patient • Review benefits • Discuss ESRD Medicare • Discuss Medicare coverage of complications for living donor • Estimate of post transplant medication costs signed by patient

8. What can be done if patient unable to afford post transplant costs • Fund raising • Medicaid screening • Discussion on other types of insurance that may be available • Work with dialysis social worker • Patient may decide to wait to proceed if unable/unwilling to explore other options

9. Committee review • Each patient is brought to committee review after evaluation • Financial coordinator is important member of this team • Financial coordinator must speak up of patient not prepared financially to afford post transplant costs, or with any known insurance issues at that time

10. Patient placed on the waiting list • Once approved for listing at committee review, it is the responsibility of the financial coordinator to obtain the insurance authorization • Each insurance company may have their own rules regarding these authorizations. • Some may require a phone call to begin process, others may require fax, etc • You may be assigned a nurse case manager

11. Insurance authorization obtained • Some insurance companies will authorize a transplant for 6 months, some for a year, and others may be authorized open ended until the transplant occurs • It is important to keep a listing of the requirements of each insurance plan so that you will know what to do at the time of listing • It is also important to keep track of when these authorizations expire, as you don’t want a patient to be admitted for a transplant without an updated authorization • I find it is useful to check each authorization at the time of reevaluation, and I also run an EPIC report that provides this information

12. Yearly letter to each patient • Each patient on the AWL is sent a letter in December of each year that discusses open enrollment and letting us know of any insurance changes • I also include a “Demographic Form” which I ask the patient to return. The form asks them the demographic information for the most recent insurance plan(s) • You would be surprised to know how many patients think that you have the correct information when you do not

13. Patient called in for transplant • If during business hours, I contact the insurance company for the admission authorization/update transplant authorization • This authorization information is provided to the hospital admitting department • I also confirm that all coverage is active, regardless of admission authorization requirements • This is especially important with Medicaid spenddowns

14. Discharge medication • We do not have a dedicated outpatient pharmacy at our center • We use transplant specialty pharmacies for the first fill of medications as they will deliver directly to our clinic. Our coordinators will bring the medications to the floor and fill the pill box with the patient in preparation for discharge • Starting month 2 patient can continue with transplant specialty pharmacy (we do order refills with original fill), use a pharmacy of their choice (some patients have a connection with their local pharmacy), or use mail order pharmacy if they choose

15. Post discharge • We meet with patient at first post discharge follow up appointment • We again review expected out of pocket costs • We review Medicare again and complete 2728 for those who were not on dialysis prior to transplant • We also let patient know that we can assist as a liaison with billing should any billing issues arise

16. What happens post transplant if patient unable to obtain medications? • Loss of insurance • Inability to afford copays • Loss of income

17. TFC will check for Patient assistance programs through manufacturer • Assist patient with applying for Patient Assistance Programs • Refer patient to speak to social worker for budget counseling • Refer patient for Medicaid application

18. Other Financial Coordinator tasks • ESRD billing/cost report approvals • Referrals (pre/post transplant) for needed testing • Liaison of many hospital departments-admitting, registration, finance, msg, specialty departments • Assist nursing staff in obtaining medication prior authorizations • Work with contracting regarding centers of excellence applications • Many, many others!

19. Take 2 Even centers That use the same system will have different processes.

20. “it takes a village” • Pre-Transplant Nurse Coordinator • Pre-Transplant Secretary • TFC • Dietician • Social Worker • Pharmacist • Medical Director • Surgeon (Recruiting for a second) • Donor Nurse Coordinator • Donor Secretary • Post-Transplant Nurse Coordinator • Nurse Coordinator Float • Post-Transplant Secretary • Transplant Administrator • Data Manager • Transplant CMA

21. Incoming referral Pre-Transplant Secretary sends referrals to TFC TFC performs initial screening to clear for Kidney Class Patient is scheduled for class by Pre-Secretary

22. Benefit Verification • Comprehensive verification completed by the TFC • Outpatient Benefits – to include office visits, labs, x-rays • Inpatient Benefits • Prescription Drugs – to include estimated copays for each post-transplant medication • Overall Benefit Structure • Initiate Authorization if required for evaluation

23. Pre-Kidney Class Meeting • Review Patients • Concerns and Observations Noted and Discussed • Organize Schedule for class day

24. Kidney Class Education Session Comprehensive Interviews Each team member has a scheduled time to see the patient privately

25. Medication co-pay estimate Sheet

26. Financial Acknowledgement

27. Awareness of Non-verbal cues Body Language Crossed Arms Deep Sigh No Verbal Reply Lack of Eye Contact Facial Expressions

28. Use These cues to drive discussion Cuesof apprehension Cues of Confidence Are you able to manage this cost? How will you manage this cost? Income/Savings HSA FSA 401K • What do you think of this information? • I sense unease, would you share your thoughts? • I know this is a lot of money – let’s talk this through…

29. Committee Review to activation • TFC attends ALL committee review meetings • Integral part of the transplant team – must communicate any concerns to the team • TFC documents financial clearance note in Epic • Insurance authorization processed once patient is cleared for activation • Formal activation on the waiting list

30. While awaiting transplant Waitlist patients seen once every six months Perfect opportunity to re-verify benefitsand keep abreast of changes Review for and process re-authorizations Reinforce education on out of pocket costs ESRD Medicare education – track of 30 month COB

31. Living donor Transplant • Follow the same screening process for the recipient • Thorough investigation of donor coverage under private and Medicaid plans • Ensure Medicare entitlement and discuss options if NO Medicare entitlement • Meet with all donor candidates to explain donor billing • Provide donors with Donor Financial Toolkit • Benefit of known transplant date – authorize admission in advance • Obtain separate authorization for donor if required by recipient insurance

32. Deceased donor Transplant • Re-verify insurance and notify of transplant admission • Some insurances issue a separate authorization number for the admission • Notify onsite outpatient pharmacy of RX coverage and anticipated copays • Pharmacy will communicate copay discrepancies and PA requirements • Post-transplant RN kept in the loop about medication copay issues • Provide copay cards or assist with medication assistance applications when appropriate • Look for any possible way to help patient save money on medications

33. Post Transplant – post donation • Check in with donors and recipients during follow up clinic visits • Remain available to patients either in office or by phone, indefinitely • Communicate patient financial issues to medical staff as needed to help coordinate care

34. Charge Analysis and Cost Report • Review all charges for recipients and donors • Process to cost report as appropriate • Release charges for direct billing to patient insurance as appropriate • Work with finance as needed to assure processes produce accurate reporting

35. In closing, no two centers will be the same • Everyone has their own way of doing things • Don’t forget to speak up when necessary • Use admitting/finance to your advantage • Try to sign up for insurance company websites. This can save quite a bit of time in obtaining benefit information

36. Questions?