The Current Payer Landscape for Oncology Practices
The continuum in which payers are managing to evidence based care varies from:
Lack of medical policy guidance for MD administered benefit with few restrictions on treatment to requiring
Pre-Authorization / Medical policy guidance on select high value products
Medical policy based on evidence based care guidelines (e.g. NCCN); increased authorization burden
Increasing Challenges to Oncology Practices
- Increasing demand to adopting standards of care and consistently achieving adherence
- Pre-certification and prior authorization; high administrative burden
- Significant resources required for personnel, informatics and decision-support tools
- Increased administrative burden and costs required to administer treatments and insure adequate reimbursement
- Post treatment delays in reimbursement and retrospective denials
Oncology Practices Need Better Solutions to Manage Care in this Challenging Environment
Key Network Management Needs
- Standardize care and improve the overall quality of care provided to health plan members
- Understand rates of adherence to national guidelines compared to a peer group of practices
- Use technology to support data collection and adherence to standards
- Offer the services of a single vendor to streamline operations and data capture; create incentives to encourage adoption.
- New paradigms for reimbursement.
Collecting Valid and Accurate Data for Practices is Key to:
- Quality-based care
- Increasing and demonstrating value to managed care organizations
- Long term viability for the practice and community oncology
- Enhancing and maintaining profitability
FCCN Offers Comprehensive Clinical Solutions to Address these Network Management Areas:
- Developed locally via a consensus-driven process
- Regimen Profiler with practice fee schedules loaded for all major payer contracts
- Clear CoverageTM- prior authorization management solution to automate requests and link directly to key payers
- Standardized care pathways for lymphoma, breast, lung and colon cancer
- Quarterly actionable practice management reports that identify opportunities for improvement
Achieving Regimen Standardization:
- Using accepted guidelines, the Practice adopts consensus developed care pathways
- Practices uses FCCN clinical and financial tools to implement standardized regimens for lymphoma, colon, breast, lung cancers
- Practice/FCCN monitors compliance with standardized care pathways
Post-Implementation Monitoring:
FCCN prepares quarterly benchmark reports on:
- Utilization
- Adherence
- Cost
- Reimbursement
- Quarterly calls are provided to review the reports and discuss opportunities for improvement
Payer Negotiations/Relationships:
- Alternative reimbursement models
- Treatment planning fees and episodes of care models for reimbursement
- Decreased prior authorization requirements
- Enhanced reimbursement for guideline compliance leading to an alignment of incentives between practices and payers
- Expertise to ensure successful payer contract negotiations on behalf of FCCN practices
Florida Comprehensive Cancer Network, LLC
- IT
- EMR
- Clinical Pathways and Practice Guidelines
- Regimen Standardization
- Guideline Compliance
The FCCN Comprehensive Program; A Physician Driven Approach to Evidence Based Care
- Regimen Selection/Clinical Pathways/Practice Guidelines
- Preauthorization/Utilization Management with Efficient Compliance Monitoring
- Compehensive Software Solutions That Integrate with Existing Practice Management Systems and EMR's to Achieve Efficiencies for the Practice
- Care Management Programs
- Quality Indicators
- Supportive Care Monitoring
- End of Life Management
- Web based Access to Single Point of Care Patient Assistance Programs, Co-pay Assistance and Drug Replacement
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