Planning for the surge: Taking a proactive approach to benefits re-verification season

(Sponsored by Cardinal Health Sonexus™)

The beginning of each year brings adjustments to health coverage for millions of Americans, whether changes in their insurance provider or modifications to formularies. What’s more, it can create uncertainty and confusion for patients and potential disruptions to care. Coverage specifics for commercial plans, Medicare and Medicaid change on a calendar year basis, with new plan terms starting on January 1. A recent analysis by Avalere looking specifically at the Healthcare.gov exchange showed a staggering 77 percent of healthcare exchange enrollees changed their plans year over year. [1] These changes prompt patient support services companies (hubs) and their biopharma sponsors to field a massive effort to check for plan changes and communicate implications of those updates to patients and their providers. This annual reverification process is often referred to as “blizzard season” in the hub services world due to the sudden flurry of activity it involves.

Biopharma companies allocate additional budgets and mark the months of December through March on their planning calendars as a critical and much-watched period for their brands and patients. Planning and preparation for reverification season can extend beyond these months as flawless execution is critical and can impact the bottom line for both expenses and lost revenues.

On the hub services side, this process has traditionally created a surge of temporary staffing to address the volume of reverifications. Planning starts as early as June with on-boarding and training of staff picking up in the fall. A smooth reverification season relies on preparation, including obtaining updated financial documents and patient authorizations. Benefits Verification Specialists call payers to verify specific patient benefits, asking questions to confirm coverage, out-of-pocket costs and prior authorization or step-edit requirements. This process is time consuming and introduces the risk of human error or inconsistent and missing information with each call.

While electronic benefits verification tools have helped make the benefits reverification process faster, the number of patients whose benefits are reported back accurately without additional manual assistance has fallen short of expectations. Recognizing the shortfalls of earlier technologies, Cardinal Health Sonexus™ Access & Patient Support took a thoughtful approach to the development of our electronic benefits technology platform, Benefit Source.

In contrast to other technology solutions, Benefit Source connects directly to payers and consumes third party data sets from private and government payers to report back up-to-date and more accurate results. And the number of payers and data sources that Benefit Source connects to is continually expanding. In addition, because of this direct connectivity, data provided back to manufacturers reflects real-time benefits coverage that is accurate on all fronts – prescription data, insurance plan specifics and treatment details. This contrasts with other eBV systems that use analytical tools and historic data to predict what a payer will cover, but don’t consider patient- and payer- specific factors, like a preferred specialty pharmacy or days’ supply quantity limits.

In its time on market thus far, Benefit Source demonstrated a significant decrease in administrative wait time – delivering results in minutes compared to more extensive time on the phone with payers. Benefit Source was recognized by PM360 as a top innovation of 2019 for the advances it delivers to electronic benefits processing.

One of the most significant advantages of Benefit Source is its scalability—the ability to perform benefits verification in large batches in very short periods of time, particularly during annual benefits verification season. For biopharma manufacturers that perform annual reverifications on patients, this process can decrease the reverification timeline by weeks or even months, while significantly reducing labor costs. In many cases, Cardinal Health Sonexus™ Access & Patient Support has managed the electronic benefits process ahead of involving the current hub services partner to reduce their workload and drive savings for the brand. (See case our study below.)

The reverification process relies on information provided by physician offices as well. This work is also moving into the digital realm. Instead of picking up the phone or faxing, HCP offices are accessing the hub via online portals.

After a secure user verification process, the reverification process can be started and supported with:

• Electronic submission of benefit reverification requests
• Accessing copay savings and activating free drug vouchers to help offset new out-of-pocket costs
• Performing patient assistance program pre-screening for those whose treatments may no longer be covered or anticipate a gap in care
• Downloading and completing appeal forms
• Checking in on access status instantly and understanding next steps.

New efficiencies are achieved as the number of incomplete forms submitted by provider offices are reduced and self-serve dashboards create quick visibility to tasks awaiting action. Portals that offer integrated copay assistance can even prompt physician offices with copay assistance resources to help address any changes in out-of-pocket expenses that come with a change in insurance coverage.

Determining your reverification season strategy requires preparation. For biopharma clients working with Cardinal Health Sonexus™ Access & Patient Support, the value realized through Benefit Source as a primary or secondary part of their reverification strategy is the ability to quickly scale up operations, improve turnaround time and accuracy, reduce the expense involved in this annual process and – most importantly – provide a clear path to care for patients.

CASE STUDY

A large US-based biopharma company with a portfolio of multiple biologic brands relies on Cardinal Health Sonexus™ Access & Patient Support to administer their patient assistance program (PAP.) January typically brings an increase in free drug dispenses as a bridge while patients wait for the third-party hub to work through the benefit verifications process. The biopharma company shared that in addition to their projected free drug costs, they were budgeting nearly $900,000 for the staffing, training and processing of reverifications for over 4,000 patients.

The biopharma company evaluated and added the Benefit Source eBV technology from Sonexus™ Access & Patient Support to their reverification strategy, attracted by the capability to batch upload patient inquiries for greater efficiency.

Results

The patient inquiries were loaded on December 31 and benefit results were delivered back to the client and their hub by Jan 2. The total time for their reverification season was reduced to ten days, compared to three months previously, and the additional three months that had been typically necessary for training.

Outstanding cases, where results were not available, went back to the hub partner to work manually with their existing staffing. The biopharma company reduced the expense of annual reverifications by $700,000.

Reference

• Only 33 Percent of Exchange Enrollees in 2016 Kept Their Same Plan from 2015. Avalere. https://avalere.com/press-releases/only-33-percent-of-exchange-enrollees-in-2016-kept-their-same-plan-from-2015 . Published March 31, 2016. Accessed May 15, 2020.

About the author

Josh Marsh is a Director at Cardinal Health Sonexus™ Access & Patient Support where he provides strategic direction on hub offerings to address business challenges and provides oversight of day-to-day operations for the access and patient support programs. Josh’s team investigates patient benefits and offers education to patients on their coverage and financial obligations. Prior to Cardinal Health, Josh spent 3 years in access and patient support, managing hub service centers for various clients. Prior to working in the hub services space, he spent 13 years in retail pharmacy, specialty pharmacy, and pharmacy benefits management.