A Day in the Life of a HCT Financial Coordinator Rajwant Dhami, Sutter Medical Center, Sacramento, California Michelle Dodson, West Penn Hospital, Pittsburgh, Pennsylvania September 27, 2017

A Tale of Two Transplant Centers Sutter Medical Center Sacramento (SMCS) 16 beds combined Transplant & Acute Leukemia Unit 2016 Transplants Performed 36 Autologous 25 Allogeneic (9 Related & 16 Unrelated) 2 Transplant Physicians 3 BMT RN Coordinators BMT Clinical Program Quality Manager Social Worker Financial Coordinator NMDP Coordinator BMT trained auxiliary staff Western Pennsylvania Hospital, Pittsburgh 20 bed unit dedicated to transplant 2016 Transplants Performed 29 Autologous 38 Allogeneic (14 Related & 24 Unrelated) 6 Hematologist/Oncologist Transplant Physicians 2 BMT Clinical Nurse Coordinators BMT Clinical Program Quality Manager Social Worker Financial Coordinator BMT trained auxiliary staff

Essentials for What We Do Financial Barriers to HCT Prescription Drug Coverage Highlights of Benefit Verification – coincide with clinical steps Donor Billing

Aligning with Clinical Steps TFC Responsibilities Aligning with Clinical Steps

Steps in Transplantation Referral Step 2 Initial Consultation Step 3 Pre-transplant Evaluation Step 7 Step 6 Step 4 Stem Cell Collection Step 5 Transplant Step 6 Post transplant Post Engraftment

Step 1 – Transplant Referral Patient referral received by facility oncologist or outside oncologist who has been seen in facility clinic Clinical TFC verifies benefits*, confirms if facility is contracted and participates with the insurance for transplant services; obtains authorizations as required which may be for all phases or transplant phase Financial

Step 2 – Initial Consultation Patient meets with physician, nurse coordinator, financial coordinator, social worker, psychiatrist, tours inpatient unit and MSSU Clinical TFC meets with patient and donor (if applicable) reviews medical and pharmacy benefits as they relate to transplant process. Provides additional resource information. Financial

Step 3 – Pre-transplant Evaluation Patient undergoes eligibility testing (H&P, labs including Infectious Disease Markers (IDMs), disease specific tests, pulmonary function test, echocardiogram) (may vary by facility) Allogeneic donor also undergo eligibility testing (H&P and labwork) Clinical Notify the insurance transplant case manager if one assigned of the evaluation date for patient and donor (if applicable). Additional authorization may be required for certain pretesting. The pretesting results and other clinical information is sent to the insurance company for the transplant authorization. Financial

Step 4 – Stem Cell Collection - Allogeneic Growth factors are administered (stimulates the bone marrow to produce granulocytes and stem cells and release them into the bloodstream).  Allogeneic – Neupogen administered to donor (for 5 days then stem cells collected (harvested) (apheresis) for transplant while recipient is receiving prep regimen of chemotherapy, Total Body Irradiation, or both to weaken or destroy cancer cells & unhealthy marrow. Clinical

Step 4 – Stem Cell Collection - Autologous Growth factors are administered to the recipient (own donor) – Neupogen (Filgrastim), Zarxio (filgrastim-sndz), Granix, (tbo-filgrastim), Neulasta (Pegfilgrastim), Mozobil (Plerixafor) may also be needed for Autologous recipients. Clinical

Step 4 – Stem Cell Collection - Financial Authorizations obtained for (Growth Factors) Neupogen (Filgrastim), Zarxio (filgrastim-sndz), Granix, (tbo-filgrastim), Neulasta (Pegfilgrastim), for Allogeneic donor and Autologous recipient. Mozobil (Plerixafor) may also be needed for Autologous recipients. Financial

Step 5 – Transplant Clinical Financial Allogeneic – donor cells collected via peripheral blood or bone marrow within a few days prior to transplant. Cells are then infused into the recipient. Autologous cell that have been collected (and frozen) will be thawed and infused via catheter Clinical Notify the insurance transplant case manager if one is assigned of the transplant admission and transplant date; confirm if precertification of the transplant admission is required. Financial

Step 6 – Post-Transplant (Engraftment) The bone marrow and immune system are beginning to recover. While waiting for engraftment (either inpatient or close to the facility) daily lab counts, and intravenous fluids to prevent dehydration are required. Signs of engraftment (rise in white blood count) typically appear about 10-28 days after transplant. Clinical

Step 6 – Post-Transplant (Engraftment) Allogeneic recipients may require IVIG (Gammagard) prophylactically to decrease the frequency of infection. Engraftment step is typically included in the transplant contract phase. However, IVIG typically requires separate authorization. Financial

Step 7 – Post-Transplant Care Once engrafted, the patient will be required to follow-up with clinic appointments. The next key date is 100 days post-transplant. Clinical This period of time may be included in the case rate/global for specific number of days as indicated by contract. Financial

Highlights of Benefit Verification - Key Questions - Be Prepared! Demographics, diagnosis and transplant type (with codes) Physician NPI, address, phone and fax #s Primary, secondary insurance (check COB) Annual deductible, annual out of pocket max (met?), lifetime maximum, separate hospital admission co-pay? Are benefits calendar year? Is my facility CME (Center of Medical Excellence)/In-network for transplant services? BLUE plans – do the benefits require Blue Distinction? If so, can an Out of Network exception be requested if facility is not BD?

Highlights of Benefit Review - continued Prescription drug coverage- tiers, co-pays, does total out of pocket include prescriptions? Date , reference # of call to insurance and person’s name TPA (Third Party Administrator) – what transplant network if any does the plan use for transplant? What rates will our facility receive for professional and facility charges? Are there travel and lodging benefits? Who do I contact for transplant authorizations? For Allogeneic transplants – are there donor benefits? Limit? How should the related donor charges be billed?

Donor Billing–Related and Unrelated Know your contract language Does the recipients insurance require donor insurance to be billed first? What happens if the transplant does not take place?

BMT Related Donor Billing Process Patients registered under "BMT Acquisition" account BMT Related Donor Billing Process Transfer related donor charges to recipient transplant admission a. Individual donor charges converted to rev code 815 or b. w/o charges to BMT acquisition and post “flat rate” acquisition charge If the recipients insurance requires that donor insurance be billed first, register and bill as requested. Patient Receives Transplant a. Charges are routed to BMT Cost Report (Medicare recipients) b. Charges billed out to recipient’s insurance as per insurance/contract Patient Does Not Receive Transplant

Donor Billing - Unrelated Invoiced bi-monthly all charges entered on spreadsheet Once patient receives transplant – all charges posted individually as Revenue Code 815 If transplant does not take place, bill according to contract or Medicare guidelines (Cost Report), depending on recipients insurance.

Topics of Discussion Financial Barriers Prescription Drugs

Financial Barriers None or Limited -Donor Search Coverage Medicare Only Transplant Cap

Financial Barriers None or Limited -Donor Search Coverage: Search Assistance Fund (SAF) grant through the National Marrow Donor Program(NMDP)-unrelated search Related Search Assistance Grant (RSA) *These grants can be found on NMDP network website

Financial Barriers Medicare Only: Apply for secondary Medicaid Apply for Medicare Supplement plan Fundraise

Financial Barriers Transplant Cap: Seek assistance from your contracting department Check with the Insurance Plan if Patient can appeal the transplant cap Fundraise and co-pay assistance

Prescription Drugs Post Transplant Drugs Noxafil- www.merckhelps.com Gengraf- www.abbviepaf.org Cellcept- www.rxoutreach.org

Resources for the NEW TFC https://bethematch.org www.copays.org www.bmtinfonet.org http://www.childrensleukemia.org http://www.tfcassociation.com https://www.medicare.gov

Key to Success – Communication!

Contact Us! Raj Dhami Michelle Dodson BMT Financial Coordinator Sutter Medical Center Sacramento 916-454-6930 DhamiR@sutterhealth.org Michelle Dodson Financial Coordinator, Cell Transplantation Program AHNCI, West Penn Hospital 412-578-3534 Michelle.Dodson@ahn.org