Payer Update, July 2021

Payer Update

Connecting The Dots
by Jeff Amond

As a kid I loved drawing and I especially loved drawing pictures that involved “Connecting the Dots.” Connecting the Dots was a simple, yet enjoyable drawing activity for me as a kid. Today, all grown up and in my payer relations role, work activities can be anything but simple. We deal with complex insurance issues, narrowing pharmacy networks, complicated contracting language, and every issue under the sun regarding 340B. We happily take on these challenges to help our Hemophilia Treatment Center members.

Earlier this year, I had an opportunity to assist with a complex payer relations issue that in the end was resolved by the simple, yet enjoyable activity of Connecting the dots.

This all started in April 2021 when I was contacted by an HTC looking for Payer Relations assistance. The HTC had a family with two boys that had historically used the HTC pharmacy for their factor dispensing. The mom was always able to go to her employer and get an exception for the factor to be billed to the medical side and use the HTC Pharmacy. When they switched to Hemlibra, the employer no longer allowed them to do this exception and were forced to transition to a specialty pharmacy. After mom’s unsuccessful attempt to get the exemption for Hemlibra, she reached out to the HTC for assistance. The HTC team fought and fought to get the exception but the contacts they had for the employer and TPA were either unwilling or unable to make the change for the family.

At this point the HTC started reaching out to others for help. They reached out to our Hemophilia Alliance Payer Team, they reached out to their local foundation, and they reached out to a national foundation. We all took on this challenge to help this family. We hit roadblock after roadblock for months but that all changed after an email conversation our Payer Team had with another HTC. This HTC had a patient with the same employer, the same TPA, the same hemophilia product (Hemlibra) and the same insurance issue. The difference was that they found a person at the TPA that was willing to listen. A few weeks later, they had a meeting with the TPA. The TPA contact not only listened, but they were able to make the benefit changes to allow the HTC Pharmacy to dispense. Great news for this HTC.

Now all that was left for the other HTC was to have someone help them Connect the Dots. Our Payer Team was able to facilitate a conversation with the TPA contact and the other HTC. We Connected the Dots. That simple, yet enjoyable activity of Connecting the Dots was able to bring joy and relief to a family and an HTC. These two HTCs reached out to us with their insurance issues. If it were not for their willingness to reach out to us with their insurance struggles, this would have never happened.

Also in this Issue…

Notes from Joe
· Washington Update

Legal Update
· Compliance Program Check-Up: OIG’s Seven Elements of Compliance

Alliance Update
· Update on New Member Meeting