Oncology Financial Clearance Software

Financial Clearance in a Oncology Practice

Clearance for medical oncology starts when the oncologist signs a treatment plan. Staff run eligibility on each plan and confirm which drugs bill to the medical benefit and which go through a specialty pharmacy. For each infused drug, they check whether the plan needs approval, what it covers and for how many doses. An approval request goes out with the diagnosis, stage, biomarker results and the guideline that backs the regimen. If the plan wants a biosimilar or another drug tried first, the request has to match. Oncology financial clearance software tracks each request, its status and its end date against the cycle calendar. It holds a treatment visit whose approval is pending or about to lapse. Once approvals are in, the patient's share is estimated from the plan's benefits and the drug's allowed amount. A financial counselor then reviews that estimate with the patient and looks for help the patient can lawfully use.

Why Is Financial Clearance Different in Oncology?

Few specialties put this much money at risk before a single claim is sent. The practice buys the drug, mixes it and gives it, then waits to be paid. If the approval was missing, covered the wrong drug or ran out after the third cycle, the drug cost may never come back. Clearance is the step where an oncology practice protects its largest expense.

Coverage rules are also tied to the regimen, not just the patient. A payer may approve a drug only for one stage or biomarker. It may want a preferred biosimilar, or apply step therapy to a new start. For Medicare, off-label anticancer use depends on support in a listed compendium such as NCCN. Each drug in a combination can have its own answer, so financial clearance works drug by drug.

Then there is the patient's share, which can be large on Part B drugs and on oral agents. Help comes from several places, and the rules differ by payer type. Manufacturer copay coupons are off limits for patients on federal programs, while independent charities may help them. Clearance has to sort out what the patient owes and which help fits before the first cycle, not after the first statement.

What Oncology Financial Clearance Software Handles

Compendia support for off-label regimens

Medicare should not deny an off-label anticancer use that a listed compendium supports, such as an NCCN Category 1 or 2A rating. Staff attach the compendium citation to the approval request and keep it for appeals. Category 3 uses are not medically accepted. (CMS Medicare Benefit Policy Manual, Chapter 15, Section 50.4.5: off-label use in an anti-cancer chemotherapeutic regimen)

Medicare Advantage step therapy for Part B drugs

Medicare Advantage plans may apply step therapy to Part B drugs only for new starts. The plan's pharmacy and therapeutics committee must approve the program first. Clearance checks the plan's step rules before a new drug starts, including any preferred biosimilar. (42 CFR 422.136: Medicare Advantage and step therapy for Part B drugs)

Prior authorization rule scope (CMS-0057-F)

The CMS prior authorization rule sets decision and denial-reason duties for Medicare Advantage, Medicaid, CHIP and exchange plans. It does not apply to drugs. Drug approvals still follow each plan's own process, so staff track them by plan. (CMS fact sheet: Interoperability and Prior Authorization Final Rule (CMS-0057-F))

Reduced Part B coinsurance on rebatable drugs

Under the Medicare inflation rebate program, some Part B drugs carry a lower coinsurance in a given quarter. CMS now lists those amounts in the quarterly ASP files, so estimates use the current quarter's coinsurance for each drug. (CMS: Medicare Inflation Rebate Program (Part B coinsurance adjustments))

Manufacturer copay coupons

OIG says copay coupons implicate the anti-kickback statute when a federal program such as Medicare Part D pays for the drug. Counselors offer coupons only to patients with commercial coverage and point federal patients to other options. (HHS-OIG Special Advisory Bulletin: Pharmaceutical Manufacturer Copayment Coupons (September 2014))

Independent charity assistance

OIG's supplemental bulletin explains when independent charities may help federal program patients. It also warns about funds tied too closely to one donor's drugs. Counselors record each grant, its end date and the drugs it covers in the patient assistance program file. (Federal Register: OIG Supplemental Special Advisory Bulletin, Independent Charity Patient Assistance Programs (2014))

Medicare Prescription Payment Plan for oral drugs

All Part D plans must offer the Medicare Prescription Payment Plan, which spreads a patient's out-of-pocket drug costs into monthly payments. For a costly oral cancer drug, counselors explain this option along with charity help. (CMS: Medicare Prescription Payment Plan)

How Does Oncology Financial Clearance Software Work?

1. 1. Verify benefits on each plan

   A 270/271 check runs on every plan on file. Staff confirm which drugs bill to the medical benefit and which go to a specialty pharmacy.

2. 2. Build the approval request

   Each drug in the regimen is checked for approval rules. The request carries the diagnosis, stage, biomarkers, dose and compendia support, and goes out by electronic prior authorization where the payer accepts it.

3. 3. Match approvals to the cycle calendar

   Approved drugs, units and dates are tied to the cycles they cover. A treatment visit is held on the oncology infusion schedule when its approval is pending or ending.

4. 4. Estimate the patient's share

   The estimate uses the plan's deductible, coinsurance and out-of-pocket limit with each drug's allowed amount. Patients paying for themselves receive a good faith estimate.

5. 5. Find help that fits the coverage

   Counselors screen for manufacturer programs, open charity funds and payment plans that suit the patient's payer type. Approved help is recorded so it can be applied when the bill comes.

Oncology Financial Clearance Software vs. Generic Software

Who Uses It in a Oncology Practice

• Authorization specialist: One queue of approval requests by drug and plan, with end dates checked against the cycle calendar.
• Financial counselor: Estimates built from current benefits and drug amounts, plus a screen of help each patient can lawfully use.
• Practice owner: Fewer drugs given without coverage, and fewer write-offs on the practice's costliest purchases, tracked in oncology RCM reporting.