Training and learning solutions

Addressing Payer and Patient Challenges 

The Education Series

From launching a product in a crowded market to navigating complexities in market access and reimbursement, Xcenda has developed a unique series of eLearning courses designed for knowledge retention and application in the field.

 


Informed by Xcenda’s deep bench of market access and reimbursement subject matter experts, the Payer and Patient Challenges Education Series presents important information to customer-facing stakeholders to help achieve results and overcome access barriers.

 

This suite of ready-to-use modules can be made available to your reimbursement, MSL, and payer marketing teams immediately or customized to address unique nuances of your product, therapeutic class, and disease state. Designed to be a stand-alone eLearning experience or used in conjunction with facilitator-led workshops, the Payer and Patient Challenges Education Series provides:

  • Rich market access and reimbursement content continuously updated by in-house subject matter experts
  • eLearning design with adult learning principles, interactive elements, and engagement components 
  • Secured access optimized for any smart device
Designed and developed by Xcenda, the leaders in market access and value strategies, the Payer and Patient Challenges Education Series was informed through a quarter century of gathering deep payer knowledge and insights on overcoming today’s most pressing reimbursement challenges, and utilizes award-winning training design.

 

By better understanding Payers and their lens on market access, Xcenda has developed this unique series to help brand and field teams understand aspects vital to successful product launches, and address reimbursement hurdles and patient access barriers. 

Overview of Biosimilars

Time to Complete: 30 minutes

Learning Objectives: Describe biosimilars. Explore the current specialty drug market and anticipated cost savings due to biosimilars. Review the FDA approval pathway and recent naming guidance. Discuss CMS coverage, coding, and reimbursement guidance for biosimilars. Identify provider, payer, patient, and industry perspective on biosimilars.

Oncology Marketplace Trends

Time to Complete: 30 minutes

Learning Objectives: Demonstrate an understanding of the trends currently shaping the oncology market, including the rising cost of care, the emergence of biosimilars, the increase in oral oncolytics, and the shift in sites-of-care. Examine value-based care and payment models in oncology. Explore oncology medical homes, oncology pathways, and other tools for assessing the value of cancer care. Review payer management for the utilization and high cost of oncology drugs.

Specialty Pharmacy

Time to Complete: 30 minutes

Learning Objectives: Define specialty drugs and their distribution channels and models. Describe the role of specialty pharmacies and the services they provide. Understand the differences in flow of drug and payment between retail pharmacy and specialty pharmacy. Explain potential advantages and challenges of utilizing a specialty pharmacy for payers, providers, and patients. Understand how patients access therapy through the specialty pharmacy channel. Discuss considerations and best practices for payers and practices to work with specialty pharmacies to best support patient access. Outline current specialty pharmacy trends in the US healthcare market.

Reimbursement Fundamentals

Time to Complete: 30 minutes

Learning Objectives: Review the key payers in the US healthcare landscape, including Medicare and coverage under Parts A, B, C, and D; Medicaid and the Affordable Care Act; the 5 types of private payer plans; and military health programs. Recognize the major code sets used in the US for reimbursement and understand when and why they are used. Identify standard utilization management tools. Describe the key components of reimbursement, including insurance benefit verification, fee for service vs managed care structures, and different reimbursement and payment methodologies.

Commercial Payer Fundamentals

Time to Complete: 40 minutes

Learning Objectives: Explain private payer insurance options including the different types of plans available and their respective levels of restrictions and cost. Develop an understanding of the health insurance exchange, managed care, cost-sharing, and health savings accounts. Describe private payer contracting and reimbursement processes. Explain the difference between the medical and pharmacy benefit. Explore pharmacy benefit strategies, formulary design, utilization management techniques, and the roles of the PBM and P&T Committee.

Medicare

Time to Complete: 60 minutes

Learning Objectives: Describe the fundamentals of the Medicare program, including the 4 parts of Medicare and the premium, deductible, coinsurance, benefits, and services associated with each, as well as how supplemental coverage can help cover costs. Learn how the Affordable Care Act has impacted Medicare Part D. Explain how Medicare makes national and local coverage determinations. Review Medicare Administrative Contractor reform. Define Medicare quality reporting programs and list programs currently underway.

Medicare Part D

Time to Complete: 45 minutes

Learning Objectives: Paraphrase the Medicare prescription drug benefit (Part D) including key policies, eligibility and enrollment, benefit designs, and market dynamics. Explain the Medicare Part D low-income subsidy benefits and resource limits. Describe the key features of the Part D exceptions and appeals process.

Medicaid

Time to Complete: 45 minutes

Learning Objectives: Describe the different types of Medicaid programs, their history, and structure. Discuss the impact of healthcare reform on Medicaid programs, including state decisions on Medicaid expansion and work requirements. Differentiate between optional income level requirements and mandatory Medicaid-eligible groups. Describe Medicaid eligibility types for children. Define dual-eligibility, including full benefit dual-eligible, the Medicare Savings Program (MSP), and the associated MSP-enrollee categories. Define Managed Medicaid and the types of organizations that provide Managed Medicaid benefits. Explain the benefits of risk-based managed care. Learn how to determine coverage, coding, and payment for Medicaid services and list the mandatory and optional Medicaid benefits. Understand how state definitions of medical necessity apply to Medicaid. List Medicaid utilization management controls and Medicaid provider and drug payment methodologies. Discern nuances of the reimbursement process as they relate to Medicaid. Explore several case studies as they relate to Medicaid.

Practice Analytics

Time to Complete: 20 minutes

Learning Objectives: Describe the work flow overview and the revenue cycle phases and processes. Explain key practice indicators (KPI) and their purpose. Explain commonly used front office KPIs (benefits verification, schedule utilization, no-show rates, and time-of-service collections), business office KPIs (charge entry lag, clean claim rate, average days in Accounts Receivable, denial rate, bad debt adjustment percentage), and other commonly used KPIs. Describe tips to build a customer-focused relationship, including how to use probing questions to determine each practice’s needs and challenges.

Navigating Hospital Decision Makers

Time to Complete: 30 minutes

Learning Objectives: Describe hospital leadership structures, quality performance considerations, and national trends such as per capita hospital spending, cost containment, and purchasing. Learn about variations in hospital payment methodologies and how the Affordable Care Act has introduced the accountable care organization model of care, bringing new challenges. Explain how the Medicare plan benefit design depends on the hospital level of care and what hospital care Medicaid covers. Describe key decision-making structures in the hospital setting. Learn who influences product access and how decision-making forums and committees function. Discuss key messaging parameters and best practices for interaction with hospital customers. Describe the impact of successful collaboration with hospital decision makers.

The Revenue Cycle

Time to Complete: 45 minutes

Learning Objectives: Explain the steps of the revenue cycle and how the steps interact with one another. Discuss some of the best practices for benefit investigation, clinical documentation, prior authorization, coding and billing, claims management, denials and appeals, and explanation of benefits (EOB), to develop the most effective processes within the revenue cycle. View sample billing forms with explanations of important fields. Discuss effective ways to manage claims, work with clearinghouses, and prevent denials from occurring. Understand the appeals process should a denial occur. Review an EOB and the different types of information it carries. Understand the role of Accounts Receivable and how to manage the department’s processes.

Coding & Claims

Time to Complete: 30 minutes

Learning Objectives: Explain the fundamentals of claims. Understand the importance of compliance. Learn how and when to use the different types of electronic claims forms. Explore and differentiate between ICD-10-CM diagnosis codes, HCPCS codes and modifiers, CPT codes, and NDC codes. Understand how and when each type of code is used. Articulate the submissions process for a clean claim for each site of service. Review the work flow and learn how to avoid common clerical errors that can lead to a denied claim. Discover how to appeal a denied claim, including the specific Medicare appeals process.

Navigating the CMS Website

Time to Complete: 45 minutes

Learning Objectives: Research current average sales price (ASP)-based payment rates in the physician office. Explain Medicare physician fee schedule payment by geographic area and know how to search for pricing, policy, relative value units, geographic practice cost index, payment amounts, and Medicare Administrative Contractors and their localities. Locate current hospital outpatient ASP-based reimbursement rates, and understand Addendums B and D1. Navigate the Plan Finder. Identify resources to understand the 5 levels of Medicare appeals and the Part D exceptions and appeals process. Locate benefit manuals and the Medicare & You Handbook. Examine Medicare coverage policies (including articles and bulletins), with sample national and local coverage determinations. Navigate the Medicare Learning Network.

Understanding the Explanation of Benefits

Time to Complete: 40 minutes

Learning Objectives: Describe the details of the Explanation of Benefits (EOB). Define frequently used terminology related to EOB. Paraphrase the revenue cycle. Examine sample EOB. Identify and walk through sample contractual adjustments and common denials requiring additional information. Review remark codes and common claim denials.

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