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Survivorship and Insurance

August 23, 2018 | What Would Lillie Do?

Name: Randi
Position: Nurse Navigator
Subject: Care Plans

Question:
Hi Lillie,

We are looking for feedback regarding administration of survivorship care plans. Our Nurse Navigation program has been asked to administer care plans. The care plans have been created via our Cancer Registry. They are extrapolating data and completing care plans. Nurse navigators are then responsible for reviewing and coordinating with the patient to administer the plan. We understand it is within our scope to administer care plans, but we have noted some discrepancies with care plans, and this has been a newly added job responsibility. Additionally, our medical oncology providers are private; they are not administering care plans, nor are they reviewing our care plans. We wonder as nurses if there is any liability in administering a care plan with incorrect information, as well as what other community hospitals are doing to meet the standard. At the end of the day, we believe the information is so important, and we want to do the best for our patients. Thank you so much!

Answer:
In most settings, a nurse practitioner is creating and reviewing the treatment summary and Survivorship Care Plan (SCP). This way, it is a billable service. With that said, the nurse practitioner must be a member of the team that took care of the patient. There is a requirement in the CoC Standard 3.3 that the survivorship care plan be created by a clinician who had been involved with the patient’s treatment. This means the tumor registrar can create it but it must be reviewed, edited, and confirmed to be accurate before the patient receives it. 

Oncology nurse navigators are in a good position to help ensure the SCP that contains the follow-up screenings, importance of adherence to meds, and promotion of healthy lifestyle behaviors to reduce risk are carried out first through patient education and the scheduling of the follow-up tests and exams. 

The primary care physician must have a copy, as well, and the plan must make clear his/her responsibilities.

I hope this is helpful. 


Name: Christin
Position: Nurse Navigator
Subject: Survivorship

Question:
Hi Lillie,
I’m wondering if you have any ideas for me. I work for a large hospital system that sees high volumes of patients from many different private practices that are contracted with our facility. Currently, our nurse navigators do not oversee survivorship. We are trying to find a way to identify our survivorship patients. What do you suggest for facilities where physicians are not employed by the hospital and where there is no survivorship clinic in place?

Answer:
Technically, the treating provider is responsible for the treatment summary and SCP. It’s hard for nurse navigators to be responsible for something over which we have no control.

I recommend inviting these private practice doctors in for a dinner meeting to discuss this and figure out as a team whether a process can be created that works well, making the patient the priority. You might be surprised that some of these doctors are doing a great job with survivorship care. Some may have chosen to follow their patients forever. You may even find that one or more of the doctors would be interested in developing a survivorship clinic with you. 


Name: Lisa
Position: Nurse Navigator
Subject: Insurance

Question:
We are running into insurance companies denying or delaying authorization of staging imaging (even if it is an NCCN recommendation) and referrals to bigger institutions/surgeons for complicated cases. We have also had insurance companies tell the patients that they are waiting for records from us (blaming us) when it is the insurance company playing “God” with the patient’s care. How do you address such a situation? What do you say to the patient when their insurance is dictating their care, denying care, or delaying care? Many times, the patient doesn’t know who to believe is the problem—the hospital or the insurance—because one of us is outright lying. How do you instill confidence that we are being their advocate when insurance companies contradict us? Why is there not more public outcry and health policies about how insurance is dictating the care we provide?

Answer:
Your vice president of medical affairs must speak directly with the physician advisor or vice president of medical affairs for these insurance companies and get this settled. Delays are built in to slow down payments. Patients are caught in the middle. It’s terrible.

I recommend letting a newly diagnosed patient know up front that you have historically had difficulty with their particular insurance company so they are not surprised by any delays. In the meantime, your vice president of medical affairs must emphasize that delays in care of patients with cancer can result in the cancer growing and the patient’s progression to a higher stage that correlates with higher mortality, which could result in lawsuits for the insurance company. 

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