The Innovator Awards recognize Association of Community Cancer Center member programs for their ingenuity and pioneering achievements in oncology. Innovations advance the goals of improving access, quality, and value in cancer care delivery.
The UNC Hospitals Department of Pharmacy received a 2019 Association of Community Cancer Centers (ACCC) Innovator Award at the the ACCC 36th National Oncology Conference, October 30 – November 1 in Orlando, Florida.
The department was selected for the award because of its development of a comprehensive, closed-loop, pharmacy-managed pre-certification and denials management program for infusion drugs needed for patients at the N.C. Cancer Hospital, the clinical home of the UNC Lineberger Comprehensive Cancer Center. The ACCC previously featured this program in a video and in this story on the ACCC website.
Suzanne J. Francart, PharmD, BCPS, an assistant director in the Department of Pharmacy, said that in recent years, all departments within UNC Hospitals have desired to increase the value provided to our organization and the patients we serve. For medications that are covered via a patient’s medical benefit, typically drugs given by an outpatient intravenous infusion, there is significant financial risk to both the institution and the patient. This is related to the fact that health insurance payers often do not provide a guarantee of payment before the medication is administered. The unfortunate result is that institutions and patients are faced with financial responsibility for expensive medications after the medications have already been given.
To address this concern, the Department of Pharmacy developed a comprehensive, closed-loop, pharmacy-managed pre-certification and denials management program. The program works to ensure payment by focusing on pre-dose, proactive navigation through insurance mandated coverage requirements for infusion drugs (i.e. the pre-certification aspect), followed by post-dose claim tracking, including medical appeals (i.e. the denials management aspect). This allows the pharmacy to not only demonstrate fiscal responsibility to the institution, but also helps to mitigate patient financial toxicity through enrollment in drug support programs offered by drug manufacturers and non-profit organizations. Vital to the program’s success is the emphasis on continuous quality improvement. The closed-loop feedback process allows collaboration and decision making among the pharmacy and revenue cycle departments, with the goal of using timely data to drive front-end change.