A field reimbursement team is an extension of a provider team, advocates, and navigators. With skills and experience in coverage and access support, field reimbursement professionals can provide additional knowledge and support with healthcare offices daily.

Field Reimbursement Managers (FRMs) are skilled at coverage, patient assistance, and health policy to educate office staff and break through access issues to ultimately help patients. The role is cross-functional to act as a liaison between the manufacturer and provider office with the expectation of getting patients on treatment.

A Day in the Life

A day in the life of a field reimbursement manager can include calls from offices, virtual engagements with field partners, and planning call schedules. Since COVID-19 changed the function of many roles, the daily role also includes reaching voicemails and bounce-back due to work-from-home and furloughs.

Typically, a regular week could include:

• Monday to plan and travel

• Tuesday through Thursday for field visits to meet the weekly expectation

• Friday for our administration day which includes routing, planning, meetings, and preparation

Typically, I start my day with checking my email and customer relationship management (CRM) tool. Next, I check daily reports I receive regarding potential snags with specialty pharmacy products andsync my iPad for any updates. I converse with my sales team partners via text, email, or phone call. I keep online documentation and a personal notebook of my interactions and to-do list. Finally, I utilize a calendar to organize meetings and I check off what’s done and add what needs to be done.

Break-down of a FRM Week

It’s Monday. Before 9am, my phone rings. It’s an office asking about a product from a different portfolio. So, I take down the information and assure them I will get another team’s field reimbursement manager to them ASAP. I call the appropriate field reimbursement manager and trade off hellos, details, and goodbyes. I make a note to call the office contact back to ensure she got what she needed.

Later, I get a text from a sales rep partner on my team. He wants to connect about a potential specialty pharmacy product’s new start. I call him and we discuss that we are sure it’s a Medicare patient and sadly no grant foundations are currently open for funding. I check FundFinder just to be certain. We briefly touch on territory trends and what he has upcoming.

Additionally, I connect with my team lead and work to send out my routing – who I will call on this week, who I called on last week. My sales partners provide any insights and/ or unmet needs our territory has for me to follow up on. I add these to my to-do list. During this time, I have her remind me of what I can and can’t share – to maintain compliance. It’s important to practice compliance every day!

Exchanging Knowledge

Further into the week, an email gets forwarded to me from a team-mate. Someone in my territory (which used to be her territory) has a question. I thank her and ask for any details on the account that she can provide. I’m still new and learning, after all. I call and leave a voicemail for the pharmacist. I also send her an email. She relays the information via email, and I call her with details I can compliantly provide. Newly approved IV infusion products and Medicare are always a tricky mix.

I coach a new nurse navigator on specialty pharmacy prior authorization and what the process looks like. We talk about how the hub can support her and her patients. We touch on next steps and potential challenges that could appear during the process. I mention CoverMyMeds for prior authorization completion and highlight electronic prior authorization (ePA). We discuss cost support for each payer type – and what options there are for all patients to get on therapy. I reiterate that myself and our care coordinator are here to help and support her every step of the way. The specialty pharmacy journey is not without its unique complications. I add a note to check in on her in a week or so.

At the week’s end, I update my CRM and finally that email template I’ve been waiting on has finally been uploaded! I make a note to send it to contacts I know will value the information. I’ll also reach out to my sales partners to gauge additional interest in the material.

Providing Support

Field reimbursement managers provide support on many topics. Specifically, I receive a question from a nurse who is helping begin an in-office dispensing pharmacy (IODP) at their location. We talk about screening for low-income subsidy (LIS) with Medicare patients and how to help them apply. Furthermore, I discuss my previous experience with LIS applications. We talk about different forms: enrollment versus free drug versus benefit investigation. I reassure her this is my wheelhouse and I will be there with guidance and assistance every step of the way. It’s a lot for one person but she will be great! I update my sales partner in that part of my territory about the conversation.

Next, a nurse manager calls me about reimbursement problems on an IV product. I ask questions to gauge what the issues are. He loops in his revenue cycle team to help clarify. We discuss what was sent into Medicare and what came back. I suggest potential fixes – how an appeal may help, what to send, and who to call. It helps to assure their team that these challenges are not isolated. I routinely reach out to my coworkers to discover similar challenges in their territories. I make a note to call them and then let the office know about my findings.

It’s Friday. My field reimbursement manager national team has its weekly call. We celebrate wins and commiserate on challenges. This time is also used for updates, reminders, and training. We share pictures and stories to end the week. I spend much of the day planning for the coming week, searching my account list for opportunities, and scouring LinkedIn and Google to get to the right names and contacts at each place.

Field Reimbursement Challenges

In case you hadn’t guessed, a field reimbursement manager (and a navigator/ advocate for that matter!) is a problem-solver. We assist in resolving reimbursement issues that may create barriers to access for patients – both for oral (specialty pharmacy) therapies and IV infusion (medical benefit). Our role makes a difference in patient access. We have considerable passion for patient care. Our goal is to help all patients get on the therapy their provider wants – as quickly and as cheaply as possible. Unfortunately, we also run into barriers. Many of which are a battle still in process.

Medicare

One of the biggest barrier-creating challenges is the government payer, specifically Medicare. Government payers require many things before they will approve a specialty therapy. And even once they approve, the therapy often isn’t affordable. This is especially prevalent with part D plans in specialty pharmacy.

“Approved does not necessarily mean free, cheap, or affordable.”

I used to coach my Medicare patients: “approved does not necessarily mean free, cheap, or affordable.” It’s a sad reality sometimes. It’s something I coach office staff on even now. I always advise giving that information up front – there are ways to get patients on therapy, but sometimes it’s much more time-consuming and extra hoops to jump through.

Thankfully in some disease states, there are options to assist patients in enrolling in grants through foundations. These grants pay secondary to the patient’s part D plan and bring their typically very high copay down to very affordable (or sometimes even $0).

Another Option

Another option is screening Medicare patients for low-income subsidy (LIS). This is a separate Medicare program (also known as Extra Help) for ‘eligible beneficiaries who have limited income may qualify for a government program that helps pay for Medicare Part D prescription drug costs. Medicare beneficiaries receiving the low-income subsidy (LIS) get assistance in paying for their Part D monthly premium, annual deductible, coinsurance, and copayments. Also, individuals enrolled in the Extra Help program do not have a gap in prescription drug coverage, also known as the coverage gap, or the Medicare “donut hole.” The amount of subsidy depends on the individual’s income compared to the Federal Poverty Level and resource limitations set by the Social Security Act’.

The last option for these Medicare patients is typically an office’s last resort: free product from the manufacturer. It can be a cumbersome process, asking a patient for detailed personal information and proof of income. The forms are long and complex. Most are submitted via fax and can take weeks for a decision. An approval, however, yields free medication for the patient and typically for a 12-month period. It’s nice to have this option in your back pocket.

Accumulators

The last barrier, which may be new to some, is the deductible accumulator programs. A copay accumulator – or accumulator adjustment program – is a strategy used by insurance companies and Pharmacy Benefits Managers (PBMs) that stop manufacturer copay assistance coupons from counting towards two things: 1) the deductible and 2) the maximum out-of-pocket spending. What does this mean?

Previously, a person could receive financial assistance from companies that make a drug, and that would count towards their deductible and/or out-of-pocket costs, depending upon the insurance plan. Pharmaceutical companies often provide financial assistance (such as a co-pay card) to help underinsured individuals afford expensive medications. This means that the person paying for the drug would end up saving money, often thousands of dollars.

The current trend in benefit design is to shift to more cost sharing for the patient. This typically results in high deductibles and coinsurance rates. Many patients are reliant on copay assistance to afford their medication. With copay accumulators, the individuals who need assistance the most will be unable to receive it. These patients will end up paying more for their treatments through the cost sharing. Fortunately, many manufacturers have jumped on board to help and offer solutions to patients on the back end of this challenge.

What’s Next

I hope this was a helpful look into the field reimbursement manager role – a role you may not yet know about. Assistance and guidance are increasingly necessary for patients to navigate healthcare and insurance – especially surrounding specialty oncology therapies. This is a brief glimpse into the impact of financial toxicity on patients and insight into potential solutions through collaboration and support from field reimbursement teams.

Deena Ayoub is a Patient Care, Access, and Field Reimbursement Professional who works with specialty and oncology products.