Case Managers Play Crucial Preapproval Role

ORLANDO--Last year, more than 80% of eligible patients at Response Oncology were preapproved for autologous stem cell transplant in an average of 28 days. "The skill of case managers has been instrumental to this success,"

Colleen Garvey, vice president of managed care for Response Oncology, said at a business-oriented transplant meeting sponsored by IBC/Infoline.

Response Oncology, based in Memphis, has been doing stem cell transplants for 9 years and has been using case management since 1992, she said. Case managers are crucial to success in getting preapproval of stem cell transplants, she said, and must be thoroughly trained and educated, as they need to have all available tools and data at their fingertips.

"This may sound simplistic, but they should understand all the industry jargon and memorize program-specific outcomes and patient selection criteria, as well as being knowledgeable about literature that supports stem cell therapies," Ms. Garvey said. "The case management department needs to have the same information that the insurance companies have."

The case managers should also have a basic understanding of insurance language related to transplants. "For instance, differentiating experimental from investigational is a real quagmire in on-cology," Ms. Garvey said. "The point is, ‘What does the payer think these terms mean?’ Be sure you know."

Other potentially unclear areas are clinical trials (since many plans exclude clinical trial services) and the term FDA-approved (misleading because the FDA does not approve transplant procedures but does approve the drugs used as part of the high-dose treatment).

Quality Issues

Case managers should be familiar with the quality issues important to payers. Insurers like to see that the program has a volume of at least 10 stem cell transplants a year; 100-day treatment survival rate of at least 95% (depending on the diagnosis); clinical staff expertise; a nurse-to-patient ratio of 1:2; excellent patient education materials; publication of program outcomes; and patient selection and clinical guidelines.

"Regarding patient selection," she said, "be upfront about, for example, whether your program considers patients with stage IV breast cancer eligible for transplant. In the adjuvant setting, which is one of the most controversial areas in case management right now, for example, do you accept high-risk breast cancer patients with fewer than 10 positive nodes? You need to be clear and straightforward about these things."

Another critical quality indicator for preapproval of stem cell transplants is whether the program has an internal medical review for clinical eligibility. "I can’t emphasize enough the importance of having a separate review board when doctors submit patients for eligibility," she said.

The use of standard protocols for specific diagnoses and specific inclusion/exclusion criteria is important. "It’s helpful to create a standard grid by diagnosis that mirrors your protocols prior to submission to a third-party payer," she advised. "This may not always exactly mirror the payer’s requirements, but it should get you 90% of the way there."

She suggested that programs carefully track patients to build a data base of all eligible stem cell transplant candidates with weekly, monthly, and quarterly reports. Such reports should include satisfaction data for patients, clinical teams, and payers, and scrupulous delineation of reasons that cases were denied.

Since outcomes are dependent on the type of population treated in a protocol, Ms. Garvey said that patient information data should be included when describing medical outcomes. "You must allow the payer to compare apples to apples, so differentiate your patient populations, therapies, and types of trials carefully."

She also suggested establishing a clear division between clinicians and case management staff, separating the two so as to avoid compromising patient expectations. "I’ve seen a tendency for clinicians to say to patients worried about their reimbursement, ‘Don’t worry. Everything will be OK.’ But until the case management department has all the necessary data, we really don’t know what the decision will be."

Finally, she said, case managers should always keep in mind that their primary role is patient advocacy, especially when cases are denied. "Secure a written appeal from the patient before appealing to the payer," she said, "and consult the treating oncologist first for additional clinical information that might be useful."

In addition, she said, the case manager should make sure he or she understands the reason for the denial and whether the language of the insurance plan supports the denial.