1. 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

2. 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

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

4. Aligning with Clinical Steps
TFC Responsibilities
Aligning with Clinical Steps

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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 days after transplant.
Clinical

14. 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

15. 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

16. 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?

17. 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?

18. 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?

19. 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

20. 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.

21. Topics of Discussion
Financial Barriers
Prescription Drugs

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

23. 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

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

25. 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

26. Prescription Drugs
Post Transplant Drugs
Noxafil-
Gengraf-
Cellcept-

27. Resources for the NEW TFC

28. Key to Success – Communication!

29. Contact Us! Raj Dhami Michelle Dodson BMT Financial Coordinator
Sutter Medical Center Sacramento
Michelle Dodson
Financial Coordinator,
Cell Transplantation Program
AHNCI, West Penn Hospital