Episode 33: How to Navigate Copay Accumulators

Transcript: How to Navigate Co-Pay Accumulators with Patient Access Experts

Dylan McCabe: WeInfuse podcast episode number 33. Welcome to the WeInfuse Podcast. My name is Dylan McCabe, and in every episode we give you a seat at the table as we interview industry experts so that you can get the tips, tools, and roadmap you need to have a successful infusion practice. And in this episode, I’m going to interview Stef Parks and Angie Baker. They are patient experts. You’re going to get a lot out of this episode, but we’re really going to focus on copay accumulators. What are copay accumulators? What does it look like for that to get worked out in a patient’s life? What’s a copay maximizer? What are best practices for providers to address copay accumulators? This is something that’s hit on the oral front. It got moved back a little bit for infusions, but it’s headed our way in the world of the infusion practice. So you’re gonna get a lot out of this. And before you do that, if you wanna learn how WeInfuse streamlines your practice and takes the confusion out of infusion, you can schedule a discovery call with one of our account executives today. You will be so glad you did, because having a streamlined practice is better for your business. It’s also better for your patients because your nurses, your providers and practitioners can really focus on the patient when they’re not bogged down on juggling 53 different details in the air on a daily basis. All right, guys, let’s jump right into this interview with Steph and Angie. Alright,. as I mentioned, I have special guests, Stef Parks and Angie Baker on the show today. So really excited to have them here. So Steph and Angie, thanks for joining the show.

Stef Parks: Thanks for having us back.

Angie Baker: Thank you so much.

Dylan McCabe: And we have the man, the myth, the legend, Mr. Reece Norris, co-hosting as well.

Reece Norris: Good morning.

Dylan McCabe: So you guys were on a previous episode and it was Take the Confusion Out of Infusion Billing”- episode nine. So for people listening to this, they want to go back and hear that was an awesome episode, but what we’re gonna get into today is copay accumulators. But before we do that, we have an announcement that Steph is gonna make.

Stef Parks: Thank you again guys for having us on the show. Angie and I are super excited to be here. I just wanted to point out that any of the opinions that are expressed today by Angie and myself are those of our own, that they’re just based on our professional opinions and our experience in the industry, and they do not reflect those of any company, corporation, or entity. We’re just here to share our passion about patient access.

Dylan McCabe: Awesome. There you go. And you guys really are, you guys are patient access experts. You guys have done a lot in this field. You’ve helped a lot of patience, you brought a lot of thought leadership. You posted a blog recently that’s on the NICA website. And it’s just great what you guys are doing to equip people in the industry. And what we’re addressing today is something new because there’s always, this is a constantly evolving landscape as we all know, and that is copay accumulators. So for people not familiar with that, let’s just give a basic overview of what is a copay accumulator?

Stef Parks: So a copay accumulator has been present on the specialty pharmacy side and oral medications for some time. So we are pretty familiar with those. A copay accumulator is an attempt by a payer or a pharmacy benefit manager to allow the copay assistance programs that are provided by the manufacturer to not go towards the patient’s out-of-pocket responsibility. So basically what that means is the patient will still be responsible for their out-of-pocket, their deductible or co-insurance up to their out-of-pocket maximum.

Dylan McCabe: Okay. So for people listening to this, how does that apply to infusion centers? This is something that’s getting rolled out. I think recently it was delayed, but that doesn’t necessarily mean denied. So how does this apply to infusion centers?

Stef Parks: So there’s been an announcement from a couple of large payers that have said that they are gonna try to attempt to introduce this into the buy and bill area. Yet, there was an announcement yesterday where it was put on hold because it was supposed to go live January the first of 2021. It’s been delayed and we don’t know how long, but that’s a big win anyway we’ll take it. So they are trying to introduce it into the buy and bill space, and I know that one of the big payers had said that the basic outline of the scenario was gonna go where the patient is infused and then the claim submitted and then basically the payer would, research to see if there is any copay assistance for that particular product. And then they would have to go back to the provider. The provider will have to basically submit to the payer if the patient does utilize those copay assistance funds so that they know how to allocate that towards the patient’s out-of-pocket.

Dylan McCabe: And so my, big takeaway from that I think I get, and I want you to add to this, is that since things are constantly changing and there’s policies that are constantly moving across the landscape, that you as a provider or business owner, you’ve gotta stay dialed into this because if it catches you off guard, it’s gonna impact your practice, it’s gonna impact your patients. And so that’s really the goal of this podcast, is just continue to equip people with the knowledge they need. So let’s share a story where this is worked out. What does it look like that a patient is being affected by copay accumulators, going to a practice to get treatment? Share the story of how that gets played out.

Angie Baker: Yeah. So I can share maybe not in practice, it all is the same. We saw a very large increase in consistent issues from patients expressing that they have out exhausted their copay card and they haven’t met their deductible and researching it. It’s pretty new even in the specialty oral side of things. And even for us and even for the reimbursement hub managers who are experts in navigating those benefits every day. It took them a while to really identify or know which questions to ask during that BI and finally found that it was an accumulator plan type. But we have a lot of activity. We’re looking at a lot of benefit investigations, like the volume is huge. And we saw probably in June, July of this year a lot more issues coming up and patients exceeding their copay card, not meeting their benefits. It was interesting because, we first started hearing accumulator plans probably two and a half, three years ago. But this is the first year that we’ve really seen an increase that has started to affect patients personally anyway that I’ve seen. But what we worry about is it getting worse next year, that there will be more plans that choose to have that accumulator built into that. One thing that Steph and I did the other day, because we are nerds, was to investigate so we were investigating our own benefits just to see how difficult it is for us even to tell if we have an accumulator plan. And I had to dig probably, I don’t know, an hour and I still couldn’t figure it out. We determined that mine didn’t have one, but it was super difficult. So then we’re like we’ll just go, act like we’re gonna go out on get an ACA plan. Act like we’re signing up for the benefit in the marketplace. And trying to identify those plans that have those accumulators is near impossible. It’s like pulling a grain of salt out off the table.

Stef Parks: And then the other thing I wanted to point out, to Angie’s point, whenever we were trying to check our own benefits, number one, the insurance companies were like, what’s a copay accumulator? And these are people that we’re planning to implement this in January. So I feel like there’s gonna be a lot of misquoted. We’re gonna have, we’re gonna see a lot of challenges with that. Which is gonna be difficult for the providers who have to explain the benefits to the patient. When benefits are misquoted, super frustrating both for the provider and for the patient. And then also, just because a payer has said we’re gonna have co-pay accumulators on all of our plans, there’s still gonna be some self-funded plans that are large employer groups that are not gonna be affected by that because the employer has chosen not to go that route. If you hear about that, just make sure you dig into the details. It’s the fine print, it’s the limitations, it’s the exclusions, asking specific questions. How do co-pay assistance funds from the manufacturers? How are they applied? How do they affect me?

Angie Baker: That was, yeah, and I just know if, I’ve been doing this a little while and it was extremely difficult.

Reece Norris: I wanted to back up and say if I’m a patient, for example I, my plan, my insurance plan is subject to a copay accumulator. I said that correctly. And so what, so I’ve gotten manufacturer assistance, so the pharmaceutical company has enrolled me into their program. It’s been exhausted now. So the manufacturer funds have run out. What does that mean for me when I go to get my next infusion or that next prescription of drugs?

Angie Baker: If it is adopted the same way that it’s been adopted in the oral space, then that basically means once that copay, once that manufacturer’s coupon or copay assistance program has been exhausted. That’s whenever your portion starts to kick in. So if you have a $500 deductible, that’s gonna be applied to your next visit, once that copay, depending on if you had been in the hospital, already met your deductible for the most part, right? If it doesn’t happen, that’s an unmet deductible. If there’s nothing gone that’s gone towards that. And where my concern is, we have patients that are chronically ill, quality of life medications that are very expensive, and the manufacturers are doing everything that they can to make these medications affordable, to subsidize that cost. And then you have payers that are gonna turn around and take that money, and then they’re also going to squeeze every dime out of the patient too. Which is frustrating because you see the customer, the patient is the customer of the payer of the insurance company, and so they’re really backing their patient into a financial hardship.

Reece Norris: Yeah. That’s just from a manufacturer perspective, that’s all about adherence. , and then, Got primary adherence. So you’ve gotten the script, you’re on the drug, but this is really gonna contribute to that secondary non-adherence. I got off. Why didn’t the patient get off? And it’s gonna be a reason that they couldn’t afford the drug anymore. And they’ve exhausted covid assistance, which is terrible.

Dylan McCabe: But what we’re talking about, bottom line is more money out-of-pocket for the patient. Which is crazy because they’ve been paying premiums for so long and then you get ’em to a point to where it’s oh, we’re gonna help you out a little bit. But maybe for the last four months out of the year, three months out of the year, you’re on your own, which is just crazy.

Stef Parks: Yeah. And what’s really scary is if you have that patient in that situation and they go to the pharmacy and they say $500, and they’re like I’m not taking it anymore. And then the person in the office doesn’t know about an assistance program, then they stop therapy. That’s where it really affects the patient.

Dylan McCabe: So who’s responsible for so much of this is about equipping people with knowledge. Equipping providers with knowledge providers, equipping patients. What, so what’s the key to that? How do you solve that? Because I’ve been in situations where I’ve gone to, I took my little girl to a doctor’s visit a few weeks ago, of course, to do a covid test. She got sent home from school because a kid in her classroom had a high fever or whatever. I’m like, okay, so we go through this whole deal where she has to get tested, right? And they say there’s two types. There’s a fast one and a slow one. There’s one we can do. You get the results today, and then there’s one where it takes a few days. That was all the education they did. And I was like, okay, why would I do the slow one? And they’re like, and by the way, the fast one is a lot less invasive. Okay. I still had to hold my five year old down with her crying saying, daddy, please no, and go through this whole ordeal. At the end of it, they, the doctor gave me a note that said she still needs to stay home for 14 days because this test isn’t seen as authoritative in the school system, but the other one is. I’m like, wait a second. What? . Why didn’t we just go through that? So there’s a huge, I feel like the burden should have been on the practice at that point to educate me on, hey, here’s two options, but here’s what the, here’s how that gets played out. So in the context with the provider for these copay accumulators, how does that work? How can the provider equip the patient because the patient doesn’t know. Like you went through it yourself, Angie, and you weren’t even sure. And you’re an expert.

Angie Baker: Number one, that’s part of the reason that we have, we did the blog for National Infusion Association, and we’re here. We’re just trying to reach people. We’re just trying to educate them and, also a good resource, and I don’t know, a lot of providers may not know that there are a lot of access specialists, field reimbursement, access specialists that work directly with the manufacturer and they support those drugs. Those people are experts in those drugs that they support. So reaching out to them is gonna be huge. They a lot of the time can come up with a solution guide and n avigate through those challenges, and know what the options are gonna be. Also trending, if you have a practice, make sure that whenever you’re checking benefits, you might have to check them a couple of times. Utilize the hub services that go along with the manufacturers so that you can compare benefits. I think that it in the beginning, whenever those things are implemented into those plans, it is gonna be huge because it’s gonna be a lot of legwork. You’re gonna have to call and everybody knows you can call the insurance 32 times and get 32 answers. You know what I mean?

Stef Parks: And I think another thing to just know if you’re working in a practice or in an office, if your patient is expressing a financial need, just know most of the time there are always resources available. Most of the time patients do not have to pay so much money for these drugs every month. So reach out to your access manager. Your sales rep with whomever you’re working with. And if you don’t know who they are, reach out to your sales rep, because I know you probably know who they are. They’re a whole lot and they’re great. But yeah, so that’s one piece of really good information for you guys working in the office.

Reece Norris: Stef, and when you worked at Innovative Infusions, shameless plug, we used to work together, you were really good at helping patients find those solutions that were a little bit out of the box. And so you were always trying to help them, put them towards foundations, and other places to find money essentially to help them get access to these drugs. So what are some of those resources?

Stef Parks: To your point, Reece, we weren’t just full revenue cycle management, we were patient advocates as well. So everybody that worked at Innovative was a patient advocate. So we had lots of different resources. We did utilize, I had lots of favorite sales reps and field reimbursement reps that we would call whatever that we would see trends, something that had gone wrong. And they would, we’d pull them in and they’d be like, oh, let me get back to you, or whatever. And they would come with a solution. This, it was an error at the payer or whatever. And then we were able to work through it and get those resolved. But also to Angie’s point and Reece too, a low-income subsidy, foundations assistance, there’s needy meds.org that has a lot of information. All different kinds of websites. But like Angie said, there’s a lot of assistance out there for patients that have chronic illnesses and it’s really important to do that work for your patient, that legwork.

Angie Baker: And also, as you work through this next year, if you have a patient that’s on an accumulator plan, say they’re a commercial patient, they have a copay card or whatever, they exhaust that benefit, just know that, reach out to the manufacturer, there most definitely is a financial hardship. They can, most of the time, go over to the Patient Assistance Program and get free drug through the end of the year. Again, just reach out.

Stef Parks: Yep. There’s the call centers for the manufacturers that do a lot of benefits, investigations, and they help with prior authorizations, at least, help navigate where that needs to go and how that needs to be submitted. But also they a lot of the time are equipped with some additional avenues once those funds have been exhausted. It’s always worth a call out to the manufacturer and who, whomever, their call center or whatever, it’s always worth a call there for a patient. And then, we used to keep up with what manufacturers had and what plans. There’s some manufacturers that have programs that do support governmentally insured patients and then there’s some that do not. So it’s important to note that so that you know which avenue to go, because it’s gonna be widespread with if there’s big payers that have this happen. You wanna make sure that you are prepared for any of those situations.

Dylan McCabe: Yeah, and I think for providers listening to this may think, oh, that’s one other thing I’ve gotta keep up with. How do I stay on top of all this? But you guys have listed a few options where you’re tapping into the resources of other experts to get them to do some educating. But also just a big thing that, that we talk a lot about at WeInfuse in consulting is having processes that are well documented, illustrated, and followed by all. So you’ve got a process driven practice and there’s ways providers can find a way to list some of these things that you guys have mentioned here, whether it’s copay cards, monthly copay costs, education websites like you listed, and just have that as like a standard procedure when patients come to the office. Say, “Hey, here’s something that might be coming up. Here’s some things to look into to educate yourself as well.”

Angie Baker: Yeah, I think a big thing is, especially after January one, ask that key question whenever you’re doing a benefit of investigation, is there a copay plan, accumulator included in this benefit for this and then yeah. And also how our manufacturers assistance funds applied to the patient’s out-of-pocket. Do they go towards the patient’s deductible co-insurance or out-of-pocket? Those are gonna be huge questions and get ready because there’s gonna be some reps at the insurance companies that haven’t been trained or educated, and they are unaware and there’s gonna be some misquoting going on. And again, frustrating. But, if you utilize those manufacturer’s hubs to cross reference your benefits investigation, at least at the beginning when this comes out ,it might be beneficial just so that you can have a double check and another set of eyes.

Reece Norris: And this just reiterates that providers have to get involved in the National Infusion Center Association because they are pushing back and advocating on behalf of the patient to the health plans. And I think they were a big contributor, communicating to United Healthcare, and which is why United Healthcare delayed that decision. It hasn’t been taken off the table, but at least it’s been delayed so that patients are able to not have to be subject to an accumulator on the buy and bill site yet. And so let’s just keep advocating on behalf of those patients at the, at NICA.

Dylan McCabe: Yeah, that’s a great point.

Stef Parks: And I agree with you a hundred percent. The National Infusion Center Association is a huge resource. And additionally, like Reece’s point, just stay involved. Make sure that you are aware of the changes that are coming down. The delay is definitely a win. We’ll take it , hoping to reach a large audience just so that we can educate on these types of things.

Dylan McCabe: So let me ask you this, you mentioned on the blog and everybody needs, so we can put the post to the blog in the show notes of this podcast because all this gets covered in the blog as well. But we’ve talked about copay accumulators. You also mentioned in the blog, copay maximizers. So what’s the difference?

Stef Parks: Yeah, it is pretty confusing because they’re both pretty new. So copay maximizer is it’s more beneficial to the patient. So they’re still an. Later plan involved. But whenever they run that copay card and say that normal copays, $50 with a maximizer, they’re gonna add another $50 that the patient will pay out-of-pocket. And that $50 that they’re paying out-of-pocket will go towards their deductible and out-of-pocket and out-of-pocket as to what they’re paying at the pharmacy. So they’re not having as much as a huge financial burden each month. But then, they are starting to meet their deductible a little bit at a time. So it’s a little bit confusing, but it is a benefit to the patient. They’re not having to pay an astronomical copay. They’re just adding a little bit at a time.

Angie Baker: Not as much shock value.

Stef Parks: Yeah. Not a shock value for sure.

Reece Norris: Chipping away at out-of-pocket insurance companies, it’s important.

Dylan McCabe: Insurance companies are just making it so easy for everybody. Let me ask you this. How does this correlate with step therapy? Because we have step therapy issues that are in place now. Yeah. So how does all this tie together?

Angie Baker: I wouldn’t say, I think they’re just both major hurdles for patients and things put in place by these payers. But I will say that, when we were here two years ago, we had five states that had passed legislation and we’ve had a lot of great success. We’re now up to 25, so that’s a huge win for the patients for sure.

Reece Norris: So 25 states prohibit step therapy.

Angie Baker: Correct.

Reece Norris: Wow.

Stef Parks: And to Angie’s point too, those are access barriers, both of them. The copay accumulator is an access barrier on the financial side. And then the step therapy is an access barrier. Because accessing the medication, the payer has made it so difficult in some situations with step therapy. And then we’ll have to file letters of medical necessity or formulary exceptions and things of that nature. And then once that provider is able to get that approval after all that administrative work, then we get to the point where the patient can’t even afford the drug after the manufacturer has done everything that they can to subsidize the cost. So it really is the united, it is really the insurance companies that are really interfering with patient treatment.

Dylan McCabe: Yeah, no, it’s crazy. It doesn’t matter what field it is, whether it’s insurance for your home or insurance for your healthcare, it’s just endless hurdles and hoops and little nuanced details and nobody talks about it until it’s too late for the patient. But let me ask you this. If you guys were, if I had an infusion practice and you wanted to come in and say, Dylan, look, we wanna make this simple for you. Here’s three steps to follow with your patients to make sure nobody’s surprised by the outcome of this stuff if it comes into the infusion center. Here’s a few things you need to make sure you do every single time. Like how can people easily fit this into their process?

Angie Baker: I think it’s just making sure you ask those questions during the benefit investigation, asking if there’s a co-pay accumulator in that plan type. And then, during that benefit investigation, you’ll know if there’s step therapy involved, if they have to try and fill other medications first. But also know if they do have step therapy involved, that they do not have to actually do those first triumphs. You can appeal it, you can appeal those denials and work towards, and a lot of manufacturers, they’ll have free drug programs and help work you through those appeals processes and eventually get onto therapy. So I think my biggest thing is just ask the right questions, be super detailed and then just don’t take no for an answer. If your doctor wants your patient on a particular drug, most of the time you can’t get it. You just have to fight for it. It’s not, it’s definitely not easy.

Stef Parks: And going through that process, I know we talked about that the last time. It’s so important to support the appeal process. That is how we see changes in payer landscapes. And then also knowing what manufacturers have what funds available. Just in case, you do have a patient that is gonna have a copay accumulator, you know what your options are and you can educate the patient. Listen, you might see this, in month six, but this is how we’re gonna work around that. Just because you know what other options are available. And if you have a patient that’s been on therapy for a while and their insurance changes and they come back and you do another BI and you hear therapy and this one’s not approved, just fight back. Because you do not want to switch that patient’s therapy,

Angie Baker: Continuity care.

Dylan McCabe: And I just can’t help it, I gotta make a plug here for WeInfuse software just because if people are not using it, the whole purpose of the software is to streamline and simplify the process. It’s a very complicated process, but there are steps you have to take inside the system when you’re doing that BI and carrying out the whole insurance workflow with the patient to make sure you don’t forget to ask one of those questions. You don’t forget to check one of those boxes and the system’s designed and make sure you get that stuff covered before you move on to the next major steps. So for those of you listening, you definitely owe it to yourselves to go to weinfuse.com. And just schedule at least a discovery call. You’re not obligated to buy anything during the call, but you owe it to yourself to at least get educated on how the process can be dramatically simplified. So I think at this point, we could go really into the weeds with all this stuff, but I really think everybody’s simple call to action is to read the blog. We’ll post it in the show notes, but what’s one big parting piece of advice you have for listeners who are like, okay, I just got inundated with all this stuff about copay accumulators. What’s one key takeaway from all this?

Stef Parks: For me, providers should know that there’s support out there. And like I said before, there’s a lot of manufacturers that have a person that specializes in those medications and can help educate you on how to work around those things. How to, what’s available for your patients and stuff. So utilize those resources, reach out to those manufacturers. See, again, Angie said earlier, talk to your sales reps. Your sales rep will know who their counterpart is on the reimbursement and access side. Just know that those people are super passionate about getting your patient on drugs expeditiously. So use those resources.

Angie Baker: Yes, most definitely. These pharmaceutical manufacturers want patients on their medications. So just know that insurance companies also have steps in place to say no the first time and they’re always probably gonna say no the first time. Just don’t fight through it. Don’t take no for an answer. Do the work. Be passionate. And if you have, if you get a no, or you get a denial and you need assistance, reach out to your access managers. Because we’re some of the most passionate people in the field and we wanna ensure that patients get access. If you get a no and you need help, just reach out to your, your drug manufacturer’s access person, right?

Stef Parks: And just to support. Those people, those field reimbursement access specialists, they help support the prescribing decision. So if once the prescribing decision has been made, then you’re a field reimbursement person that works along with that medication is there to help push and make sure that is supported. So to get that medication for that patient and take the lift and the burden off of the staff at the office.

Dylan McCabe: Alright. For those of you listening, you’ve heard from the experts, there’s resources out there and don’t take no for an answer. Stephanie, Angie, thank you so much for joining the show. We sure appreciate it.

Angie Baker: Thank you. So good to be here.

Reece Norris: Thank y’all. It was awesome. Loved it.

Dylan McCabe: All right, lots of value there from Stef and Angie, and I love what they said about, be passionate and focused and don’t say no, or don’t take no for an answer when it comes to pushing, really pushing forward for being an advocate for your patients. As always, I hope you got a lot out of that. If you did, please take a minute to rate and review on iTunes. It helps us get the word out. And again, like I said at the beginning, if you haven’t done so, you really owe it to yourself to schedule a discovery call. Learn about the WeInfuse software platform. It is unlike anything else available for owners and operators in infusion practices, and you just owe it to yourself to get the best tools possible to have a great practice in a healthy business. Okay guys, this is Dylan McCabe with the WeInfuse Podcast, and I will catch you in the next episode.

Guest Speaker: Field ReImbursement Managers at Sun Pharma, Stef Parks and Angie Baker, are infusion patient access experts with over 20 years of experience. With a BS in Healthcare Administration/Management, Stef has worked in neurology, cardiology, oncology, and more. Angie worked in specialty and home infusion management for over 10 years before joining Sun Pharma.