For: Children’s Oncology Clinic
Situational Challenge
The rapidly changing oncology and hematology therapeutic drugs landscape creates confusion about referrals, medical appropriateness and payer reimbursement. Newly developed drugs have higher costs and higher payer resistance to reimbursement until proven, consistent protocols are established and followed.
In this facility, increased referrals for outpatient infusion therapeutic drugs were creating unpredictable cost spikes and payer reimbursement process difficulties. Inconsistent interpretations led to unpredictable costs and difficulty in supporting claims for these expensive therapies. Providers on the leading edge of newer treatments are more likely to be affected by this seeming paradox.
Project Activities
The clinic director and a Productivity Healthcare consultant assembled information from various leading clinics and current insurance reimbursement schedules that medical providers determined they needed to make consistent, ethical medical decisions and then convened a two-day facilitated problem-solving session.
The Chief of Staff plus several highly regarded specialists and infusion nurses were led by a Productivity Healthcare consultant to create a way to consistently interpret new protocols and integrate them with treatment. Review of treatment protocols with outcomes, service and cost considerations were fed into a multi-criteria decision matrix to create prioritized therapeutic treatment options. An action plan was created for piloting the new process and matrix to assure viability of the new system. Administration worked with medical staff to get revised standard treatment protocols into insurance databases for quicker claims payments and fewer denials.
After two weeks, the consultant led the team in review and refinement of the new process standard documents. Once stabilized the new process was replicated at two other clinics, led by the same consultant with support from the medical team at the lead clinic.
Improvements, Benefits and Key Outcomes
The team created standard decision tools for therapeutic drugs consistent with medical ethics. The decision tools and process were replicated across other clinics in group.
The key outcome is that current care is now consistent with best medical knowledge, mitigating legal risk by creating medically defensible standards and ensuring predictable treatment costs.
Project Duration
- 3 months