The work group identified the need for a “gatekeeper” to
proactively address payer restrictions when patients are
referred for infusion services. Leaders created an infusion
advocate role to streamline prior authorization and patient
intake processes. Infusion advocates determine the optimal
site of care based on patient and payer factors. The
advocates also help ensure that Avera will be reimbursed
for the care.
Infusion advocate core functions
Infusion advocates optimize site of care and ensure care
continuity for patients. Their responsibilities include:
- Conducting pre-infusion benefit investigations
- Synthesizing payer policies, quality and safety metrics,
and patient preference to determine the best setting
for an infusion
- Checking scheduled infusions to ensure active
authorization and manage appeals
- Collaborating with infusion schedulers to ensure care
continuity for infusion patients
- Working directly with patients to facilitate financial
assistance, such as enrollment in free drug programs
Maximize impact by deploying existing expertise
The infusion advocate role builds on expertise developed in
Avera’s specialty pharmacy advocate program. Prerequisite
competencies include prior authorizations, pharmacy
benefit investigations, pharmacy billing, and health system
pharmacy services. While the infusion advocates’ workflow
mirrors that of specialty pharmacy advocates, infusion
advocates have the added challenge of working across
both pharmacy and medical benefits.
During their training, new infusion advocates meet with
each of the work group stakeholders individually, across a
three week period. The training covers topics such as
medical benefit billing, communication, handoffs, and roles.
Advocates spent time with clinic staff to better understand
medical authorizations for infusions.
Before going live, infusion advocates demonstrate their
ability to identify the best solutions for different patient
situations by working through sample cases.