How Payers Can Improve Cancer Patient Navigation, Experience

Streamline, improve appeals processes

Streamlining the appeals process is an important step in simplifying healthcare navigation for cancer patients.

“If the appeals process is so convoluted or so complicated that patients cannot utilize it, then it is not really working, or at least not working as it was intended,” said Culp.

Patients might easily become discouraged about appealing claims for necessary cancer care due to the rate of denial, even for in-network services. 

In 2019, payers on the Affordable Care Act marketplace denied 17 percent of all in-network claims, with the highest rate of denial in catastrophic plans. Less than one percent of those denials were appealed and, of that one percent, 60 percent were still denied after the appeals process.

The share of patients that appeal a claim may be low, but that does not mean that patients are happy with their coverage, Manatt Health found. Patients may avoid appealing a denial because an appeal can prolong an already complex and time-consuming process of securing care for patients who may be facing time-sensitive conditions.

It can take anywhere from days to weeks for patients to resolve barriers to care in some states’ Affordable Care Act marketplace plans, Morin and the Manatt Health team found. Paperwork errors and other unpredictable factors processes can further elongate the patient journey.

The Manatt Health analysis recommended that states implement stricter guidelines around insurers’ requirements to inform patients of their appeals rights and proposed more targeted information for patients with rare or complex conditions, for whom navigation is often an extra burden.

“A key message is that payers in partnership with the state should ensure that appropriate resources—which can be educational or on-the-ground support in navigating these appeals processes—are in place and that they are transparent about how to actually access them,” Morin emphasized. 

New York stood out in the Manatt Health study for its level of transparency around the appeals and grievances processes in its marketplace plans. It also provides information on the internal and external appeals processes in an accessible format along with a database of external appeal decisions.

The New York Department of Financial Services publishes a guide that shares the annual number of complaints and the portion that were resolved in favor of the consumer. In 2019, the department received 1,184 complaints. Consumers won in over 650 of those cases.

Consumer assistance programs can also help members find health plans that fit their needs and prevent them from having to appeal a denied claim. States and insurers can dedicate funding to such programs in order to improve patient education.

Reform network adequacy standards

Many states link network adequacy to appointment wait times, travel time, distance, or provider-to-enrollee ratios. However, these metrics do not always rely on clinical standards to inform their benchmarks and may not account for increased specialization in healthcare. 

Among the four states that Manatt Health studied, New Hampshire and Washington were in the process of reforming their measures. Their changes could help inform payers’ practices and broader regulatory adjustments.

New Hampshire evaluates network adequacy by service level, as opposed to specialty level. There are three categories for services—core, common and specialized—and cancer services can be found in all three categories. Mammograms, for example, would be considered core services, chemotherapy is common, and radiation therapy or biopsies would be considered specialized.

The state of Washington has developed a list of five changes that insurers might make that would affect network adequacy and requires insurers to inform the insurance commissioner if they enact any of those changes within 15 days. This method is designed to fix problems in real-time, as opposed to retroactively.

Changes that would require a notice to the Washington State insurance commissioner include reducing the number of specialty providers, increasing or reducing enrollee populations beyond a specified amount, and changes in hospital contracts.

“In an ideal world, the states would not have to take those steps because you would have payers and employers and the whole system set up to be more consumer-friendly, streamlined, and simple,” Culp acknowledged. 

“But the way things are now, the status quo is a little more complicated and the burden falls on patients. That is why we really need regulators to step in and implement these more nuanced consumer-centered standards.”

These changes indicate that some states are starting to think about network adequacy in a manner that accommodates the growing specialization in American healthcare.

“Thinking critically and testing these new standards—which is going to require collaboration between state regulators, payers, and even providers—we think that is really essential to advance the ball on this regard,” added Morin. “Again, the focus is on the patient, making sure that accessing treatment is easy.”

For insurers and employers that seek to improve their cancer patient navigation and education strategies, evolving state regulations such as those highlighted in the Manatt Health report as well as innovations in Medicaid may show the way forward.