When Medicare reimbursement guidelines changed in 2003, the USC Norris Cancer Hospital began to experience increases in the number of disputed chemotherapy claims and a significant amount of unpaid chemotherapy drug charges due to third party payer denials.

By 2007, Scott Evans, chief operating officer of the hospital, realized that reimbursement issues needed to be investigated in order to maintain the financial viability of USC Norris and provide consistent quality care. Thats when Shetal Desai, a pharmacist with more than 10 years of managed care experience, was hired jointly through USC School of Pharmacy as faculty and USC Norris Cancer Hospital.

Desai was given the responsibility of determining the root cause of payer disputes and implementing changes in the hospital workflow to improve overall payer reimbursement for chemotherapy drug charges.

"I found that the root cause for many of the chemotherapy disputes revolved around the issue of obtaining a prior authorization for chemotherapy treatments, especially those that were defined by the payer as experimental or off-label," she said.

In March 2008, Desai launched the Clinical Authorization Center (CAC), a clinically staffed center that employs five nurses to specifically focus on obtaining authorizations from commercial payers for chemotherapy. She serves as the director, overseeing the CAC department and continues to make improvements to the process. The CAC now obtains authorization for all payer types and serves as the single point of contact for all chemotherapy drug authorizations.

To her knowledge, USC Norris is the only cancer center that utilizes the expertise of a pharmacist overseeing this type of center.

This unique and cutting-edge management structure has apparently paid off. In addition to resolving reimbursement claims, the CAC also helps enroll patients in manufacturer-sponsored drug replacement programs. Since the inception of the CAC, $1.2 million dollars of chemotherapy drug replacements have been recovered by the USC Norris Cancer Hospital for patient use.

Enrollment in drug replacement programs has greatly improved overall satisfaction among patients and medical oncology staff, said Desai. These manufacturer- sponsored programs provide select chemotherapy drugs at no charge to qualified patients whose health insurance has denied use of a particular drug based on indication for use or if patients have reached their maximum dollar threshold for chemotherapy.

In addition, improvements have been noted by hospital finance officials in the reduction of the number of disputed claims citing medically not necessary, however, additional information needs to be collected in order to quantify the savings associated with these changes.