Ready for Some Good News?

Posted in ACCC News, Across the Nation, Cancer Care, Education by ACCCBuzz on October 1, 2014

180145256By ACCC Communications

Prepare to be inspired.

Richard Rossi, the keynote speaker at ACCC’s 31st National Oncology Conference in San Diego, Calif., October 8-10, 2014, will introduce meeting attendees to some of the country’s most gifted teenage researchers who are already changing the future of cancer care.

“With all negative news in healthcare, with all the stress and challenges as a cancer care professional, this will be a wonderful opportunity to hear how young people have fundamentally changed the future of medical care by their interventions,” said Rossi. He co-founded the National Academy of Future Physicians and Medical Scientists, an educational enrichment organization that honors, inspires, and motivates the nation’s most promising future physicians.

“Jack Andracka. He’s 17, but when he was 14 and sitting in his science class, he imagined a way to diagnose pancreatic cancer in stage I,” said Rossi.

According to Jack’s Wikipedia entry, the idea for his pancreatic cancer test came to him while he was in high-school biology class, drawing on the class lesson about antibodies and an article on analytical methods using carbon nanotubes he was surreptitiously reading in class at the time. Afterward, he followed up with more research using Google Search on nanotubes and cancer biochemistry, aided by free online scientific journals.

“At age 15 he contacted 200 professors asking for lab space to test his thesis. One hundred and ninety-nine turned him down,” said Rossi. Finally, he received a positive reply from Anirban Maitra, Professor of Pathology, Oncology, and Chemical and Biomolecular Engineering at Johns Hopkins School of Medicine.

The result of his project was a new dipstick-type diagnostic test for pancreatic cancer using a novel paper sensor, similar to that of the test strip for diabetes. This strip tests for the level of mesothelin, a soluble cancer biomarker, to determine whether a patient has early-stage pancreatic cancer. The test is over 90 percent accurate in detecting the presence of mesothelin.

“Jack is not an anomaly,” said Rossi. “The good news is that there are a whole bunch of young people making a huge difference in cancer research.”

And  cancer research is not the only area of oncology that’s engaging tomorrow’s leaders.

Some ACCC-member cancer programs are finding innovative ways to connect with the next generation of oncology professionalsfrom mentoring future oncology nurses to offering internship opportunities to tapping into the energy and enthusiasm of young volunteers in the community.

Stay tuned to ACCCBuzz for highlight’s from Rossi’s keynote talk, “The Good News About the Future of Medicine,” next Friday, October 10, 2014.

Rossi currently serves as president and executive director of the National Academy of Future Physicians and Medical Scientists. Its mission is to identify, encourage, and mentor students who wish to devote their lives to the service of humanity as physicians, medical scientists, technologists, engineers and mathematicians.

It’s not too late to attend the ACCC National Oncology Conference, learn more here.

From Distress Screening to Solutions: Patient-Centered Support

Posted in ACCC News, Across the Nation, Cancer Care by ACCCBuzz on September 24, 2014


By Don Jewler, Guest Blogger

The Edward and Marie Matthews Center for Cancer Care at the University Medical Center of Princeton at Plainsboro is a New Jersey cancer program with a tall vision to identify distress among their patients, no matter where they are within the organization, and refer them quickly to the help they need. The institution will be honored with a 2014 ACCC Innovator Award for the development of a distress tool that guides clinical staff in making timely and appropriate referrals.

“It’s been amazing how many different issues we have been able to solve for patients with the distress tool,” said Lori McMullen, RN, MSN, OCN, senior oncology nurse navigator. “One patient, for example, was having a really difficult time emotionally coping with cancer. With the distress tool, we could see that he was struggling with his diagnosis. Conversations were started. We were able to make sure he received the psychological help he needed, and that’s a beautiful thing.”

McMullen along with representatives from both outpatient and inpatient nursing staff developed the user-friendly distress tool, which uses a six-point Likert scale scoring system. Patients rank a number of concerns, including weight loss and nutrition, finances, sadness, anxiety, family, and, of course, coping with the disease. A line for “other” allows patients to write in whatever else is bothering them.

“In the outpatient setting, the distress tool is done on paper and entered electronically into each cancer patient’s electronic medical record. For our inpatients, we have worked with our IT department so that the tool is totally electronic” said McMullen.

Commission on Cancer Standard 3.2 (a 2012 standard that must be phased in for 2015) mandates that patients with cancer are offered screening for distress a minimum of one time per patient at a pivotal medical visit to be determined by the program. Some examples of a “pivotal medical visit” include time of diagnosis, pre-surgical and post-surgical visits, first visit with a medical oncologist to discuss chemotherapy, routine visit with a radiation oncologist, or a post-chemotherapy follow-up visit.

“Here, the patient might take the distress tool three or four times during the treatment cycle,” said McMullen. “As clinicians we were worried that our patients would get tired, or even annoyed, that we keep asking them about their distress level, but we have found our patients are happy that we are concerned.” At the University Medical Center of Princeton at Plainsboro, patients are screened for distress in radiation oncology at the first nursing visit after simulation, in the outpatient infusion room at the first chemotherapy visit, at the physician’s office at week five or six if on treatment, at the breast health center after a treatment plan is developed, and at the end of radiation treatment.

McMullen makes sure that referrals to support services are made. She has been the champion for implementing the distress screening tool system-wide.

“It took time to put the new process into the daily routine,” she noted. “Inviting patients to share their problems may not fit into every physician’s time frame. Although it may not yet be second nature for everyone to work the distress tool into their schedule, with gentle reminding we are getting close to 100 percent compliance.”

McMullen will speak at ACCC’s 31st National Oncology Conference in San Diego, Calif. On Friday morning, October 10, 2014, she will discuss techniques and barriers for building and implementing a system-wide distress screening tool. Come listen.

ACCC members will recognize the byline of guest blogger, Don Jewler, former ACCC Communications Director. We coaxed Don out of retirement to contribute to ACCCBuzz.

Improve Your Bottom Line with Commission on Cancer Accreditation

Posted in ACCC News, Cancer Care by ACCCBuzz on September 17, 2014

by Don Jewler, Guest Blogger

cocSure, Commission on Cancer (CoC) accreditation shows your cancer program’s commitment to quality care. Beyond that, what are the practical benefits for your institution?

For CoC surveyor William Laffey, MBA, the top benefit is that cancer programs gain access to data that they could not otherwise get about their own program. “They also gain access to comparative data to help them improve quality and understand why patients are coming to them and which patients are not. You can’t get access to the National Cancer Data Base unless you are accredited,” said Laffey, who will speak at ACCC’s upcoming 31st National Oncology Conference in San Diego, on October 9, 2014.

One set of data is on “Class 00” patients, those who come to a cancer program for diagnosis but never come back for treatment. Through analysis of the data on these patients, the cancer program can find out where they went, what treatment they had at that other facility, and, in some cases, even the referring physician.

“I’ve run into situations where large numbers of these Class 00 patients all went to a competing hospital,” said Laffey. “Their first course of treatment was for surgery. As I dug deeper, I found that most surgeries were for breast cancer. This hospital needed to improve its breast cancer surgery to keep these patients.”

When cancer programs peel back the onion, or in this case the data, they can determine exact areas to improve, including surgery, equipment, and scheduling, and they can dramatically improve their bottom line.

The National Cancer Data Base (NCDB), which is available only to CoC-accredited programs, has 15 to 20 different variables that can be compared on its 30 million patients.

Susan Rubin, MPH, of the Commission on Cancer, will join William Laffey at the ACCC National Oncology Conference. Rubin will examine key marketing strategies that cancer programs can use to maximize the value of their accreditation.

“Do you advertise the fact that your cancer program is accredited? Do you put the CoC seal on your newsletter?” Rubin asked. “It’s good to do so.”

Rubin noted that some cancer programs that go through the accreditation process do not publicize their accreditation. “Some staff in the hospital don’t even know the program is accredited,” she said. “Go out and explain to your staff the value of accreditation, their access to the National Cancer Data Base and to the Rapid Quality Reporting System.”

The Rapid Quality Reporting System (RQRS) is a reporting and quality improvement tool which provides real-clinical-time assessment of hospital-level adherence to National Quality Forum-endorsed quality of cancer care measures for breast and colorectal cancers.

If you want more practical advice on how to use the information that CoC accreditation opens up to your cancer program as well as tips on how to market that accreditation, join Laffey and Rubin at ACCC’s 31st National Oncology Conference in San Diego, on October 9, 2014.

William Laffey, MBA is the system vice president of oncology for Presence Health in Chicago, Ill. He provides a program administrator perspective to the Commission on Cancer survey process. Susan Rubin, MPH, is manager, Accreditation Program, at the Commission on Cancer.

ACCC members will recognize the byline of guest blogger, Don Jewler, former ACCC Communications Director. We coaxed Don out of retirement to contribute to ACCCBuzz.

All Signs Point to Patient-Centered Care on the Quality Journey

Posted in ACCC News, Across the Nation, Cancer Care by ACCCBuzz on September 15, 2014

By Becky L. DeKay, MBA, President ACCC

resources-Trends2014-145x195The Association of Community Cancer Centers (ACCC) has just released its 2014 Trends in Cancer Programs survey results, and our membership revealed what matters to them most—delivering quality, patient-centered care. ACCC’s annual survey provides insight on the top issues facing cancer programs today, from clinical trial accrual, to expanding use of oral oncolytics, to providing financial advocacy services, and much more.

My presidential theme during my 2014-2015 term is quality cancer care, and I firmly believe that quality is a journey, not a destination. With this in mind, an analysis of these survey results reflects how our members are continuously striving to deliver quality care with a variety of forward-thinking solutions.

One compelling new trend among cancer programs—an increasing number are proactively developing their own guidelines to help measure and track the quality of care provided, rather than waiting to be told what to do by payers. This determination to anticipate the changing healthcare landscape and to grow is encouraging; especially since only 28% of respondents reported that payers currently require quality measures.

At Feist-Weiller Cancer Center we have participated in ASCO’s Quality Oncology Practice Initiative (QOPI) to gauge our quality in clinical care, and have done very well. We also have patient satisfaction surveys, and usually our scores are high.  What keeps me up at night, though, is that we are unsure as to how best present this data to our various stakeholders who define quality care in very different ways.

For example, while “trastuzumab for patients with AJCC stage I (T1c) to III HER-2/neu positive breast cancer” may make sense to clinicians—payers and patients may not understand the clinical decision making for an expensive drug that is not without side effects. And when the patient spends more than 30 minutes in an exam room, many payers on the “judging” side (or clerical staff entering the data reported) won’t know that this reflects the fact that the patient needed more time with the physician team before making an informed decision and not that she was just waiting for a physician to arrive.

One thing all stakeholders agree on is the importance of patient-centered care. Our patients’ needs are not solely medical, a fact many cancer programs have started to address. In ACCC’s 2014 Trends in Cancer Programs survey, an increasing number of cancer programs report that they are stepping up their efforts to ensure that they are ready for the American College of Surgeons’ Commission on Cancer (CoC) standards that go into effect in 2015, including those related to palliative care, clinical trials, patient navigation, cancer survivorship, and genetic counseling. The survey also suggests that patient-centered care is driving growth in the number of supportive services being offered, including integrative and complementary therapies. This year’s survey shows that the patient-centered field of financial advocacy is thriving, with 90% of survey respondents offering financial assistance services, and 84% reporting that they have “financial specialists” on staff.

As ACCC continues to solicit feedback from its members, I hope that you will find this survey a useful resource to comprehensively evaluate your organization’s performance.

This is year five of the survey, which is a joint project between ACCC and Lilly Oncology. More than 110 ACCC-member cancer programs participated in this year’s survey. Learn more here.

Becky L. DeKay, MBA, is ACCC President (2014-2015) and director of oncology services at Feist-Weiller Cancer Center in Shreveport, La.

A Survivorship Roadmap Linked to EMRs

Posted in ACCC News, Cancer Care by ACCCBuzz on September 9, 2014

By Don Jewler, Guest Blogger

2014_InnovatorLogo finalIn a perfect world each patient who has recently completed cancer-directed therapy should receive a survivorship care plan that clearly summarizes his or her treatment and provides direction on what to expect in the next several weeks, months, and years of their life to come. That survivorship plan should be available in print form as well as easily accessible electronically on a patient web portal.

Oncology Specialists, SC, in Park Ridge, Ill., did exactly that. What’s more, they developed their survivorship care plan with the idea of incorporating many of the information points that are already collected within the patient’s electronic medical record (EMR) that essentially self-populates into the plan. The plan provides a treatment summary, including side effects, as well as health maintenance issues and the impact of cancer diagnosis on the well-being of family members.

Oncology Specialists, SC, will be honored with a 2014 ACCC Innovator Award for its EMR-driven approach to survivorship care plans.

“The impetus for development of the survivorship plan was a mandated change in the Commission on Cancer standards,” said Mary Beth Mardjetko, RN, MN, administrative director.

Standard 3.3 (a 2012 standard that must be phased in for 2015) states that the cancer committee must develop and implement “a process to disseminate a comprehensive care summary and follow-up plan to patients with cancer who are completing cancer treatment.”

Initially, after reading Commission on Cancer (CoC) requirements, Mardjetko and others in the oncology practice were worried. With limited resources and time, how could they put together a survivorship plan for all their patients?

“We saw 40-page survivorship plans. We knew these would not be realistic in our practice. So, a small group consisting of a physician, three nurses, and myself looked at the CoC requirements,” said Mardjetko. “We decided to use the template function of the EMR and build a generic survivorship plan that would be individualized for each patient using information that would pull directly into the note. We developed a four- to six-page survivorship plan with the CoC standards as the guide.”

Those standard elements include a treatment summary, drug names, doses, side effects, and names of all physicians and supportive care personnel involved. A treatment plan for years one to five is provided, as well as long-term outlook and recommendations, such as genetic testing for first-degree relatives.

Since nurses and physicians constantly update the EMR, the survivorship plan is dynamic and versatile. It can easily be sent to the primary care physician or other physicians involved in that patient’s care.

“The most wonderful part was how grateful patients were for learning what was to come next—what they could expect now and in the future,” said Mardjetko. “Physicians and nurses found the experience wonderful, too, as they went over the survivorship plan with patients and provided closure at the end of treatment.”

The next step is for Oncology Specialists, SC, to work out a survivorship plan for patients who are metastatic or on oral therapies.

“This is still a work in progress,” said Mardjetko.

Want to learn more? Join us at ACCC’s upcoming 31st National Oncology Conference in San Diego, October 8-10. Sigrun Hallmeyer, MD, medical director, Cancer Survivorship Program, Oncology Specialists, SC, Advocate Lutheran General Hospital, will provide more details. And check out a video about the survivorship plan here.

ACCC members will recognize the byline of guest blogger, Don Jewler, former ACCC Communications Director. We coaxed Don out of retirement to contribute to ACCCBuzz.

Optimism in the New Clinical Trials Landscape, Says ACCC 2014 Award Winner

Posted in ACCC News, Across the Nation, Cancer Care by ACCCBuzz on September 4, 2014

by Don Jewler, Guest Blogger


Nicholas J. Petrelli, MD, FACS

In case you didn’t notice, the cancer clinical trials infrastructure across the country is changing.

In August 2014 the National Cancer Institute (NCI) awarded 53 new five-year grants to researchers across the country to conduct multi-site cancer clinical trials and cancer care delivery research studies in their communities. The grants were awarded under the NCI Community Oncology Research Program (NCORP), a national network of investigators, cancer care providers, academic institutions, and other organizations that provide care to diverse populations in community-based healthcare practices across the United States. The program funding is $93 million a year for five years.

“I’m cautiously optimistic,” said Nicholas J. Petrelli, MD, FACS, who will be presented with ACCC’s 2014 Clinical Research Award at the upcoming 31st National Oncology Conference, in San Diego Calif., October 8-10, 2014.  “With developments in genomics and in the infrastructure of NCORP, perhaps we can make a dent in overall survival in many of the solid tumors, beyond two- and three- and four-month survival, especially in the top five cancers we see in this country.”

Dr. Petrelli is also optimistic in the area of cancer prevention. “We spend so much effort and so much money on advanced disease and even early-state disease that we are long-overdue for a paradigm shift towards prevention. Perhaps as we enter into the world of proteomics and genomics, we will be able to do a better job at preventing the top cancers. I’m hoping that NCORP will move us forward on this front.”

Thirty-four NCORP Community Sites and 12 Minority/Underserved Community Sites will implement the latest, most scientifically advanced clinical research designed and led by NCORP. These clinical trials will bring added opportunity to test new technologies and strategies to fight cancer. They will also enable research on how cancer care is delivered in today’s changing healthcare environment, all with an eye toward improving outcomes and reducing disparities of care.

NCORP replaces two previous NCI community-based clinical research programs: the NCI Community Clinical Oncology Program (CCOP, made up of the Community Clinical Oncology Programs, Minority-Based Clinical Oncology Programs, and Research Bases) and the NCI Community Cancer Centers Program (NCCCP). The new program builds on the strengths of the previous programs and aims to better address the most pressing issues affecting the conduct and delivery of cancer care in communities across the nation.

With the 34 NCORP Community Sites and a realignment of the cooperative groups, Dr. Petrelli hopes to see a rise in the annual 4 percent national accrual average of adults on clinical trials.

A major sticking point remains: adequate funding.

“We’re running on a quarter tank of gas with NCORP, and that’s not going to get us too far,” said Dr. Petrelli. “There’s got to be a change in funding at the federal level in order for the program to be successful; otherwise, we are spinning our wheels.” What’s more, he noted, we will have to find a way for hospitals not funded by NCORP to continue their infrastructure of clinical trials.

Dr. Petrelli expressed hope that resources will improve as NCORP’s infrastructure begins to grow.

As for the opportunities ahead for clinical cancer research, Dr. Petrelli singled out his top two. “First, we need to evaluate the costs of what we are doing,” he said. “We need to evaluate patients as they go through treatment—how often they get imaged or blood drawn, for example. We need to take a hard look and be very practical in the management of costs. Second, genomics, which will allow us to move faster with regard to overall survival,” as genomic data helps us improve cancer prevention, early detection, diagnosis, and treatment.

Dr. Petrelli is the Bank of America endowed medical director of Christiana Care’s Helen F. Graham Cancer Center & Research Institute in Newark, Delaware. The institution earned a five-year grant from NCORP to bring leading-edge cancer screenings, prevention, control, treatment, and imaging research trials to more people in the places closest to where they live.

Hear more from oncology thought-leaders at the ACCC National Oncology Conference, Oct. 8-10, 2014, in San Diego. Learn more here.

ACCC members will recognize the byline of guest blogger, Don Jewler, former ACCC Communications Director. We coaxed Don out of retirement to contribute to ACCCBuzz.

Why USP Should Reconsider Chapter 800

Posted in ACCC News, Advocacy, Cancer Care by ACCCBuzz on August 7, 2014

by Sydney Abbott, JD, Manager, Provider Economics & Public Policy, ACCC

question-markThe US Pharmacopeial Convention (USP) recently released draft guidance on the containment of hazardous drugs (HDs) to “as low as reasonably achievable” in order to ensure the safety of personnel handling these drugs.  According to the Centers for Disease Control (CDC), about 8 million people every year could be exposed to HDs, so USP developed Chapter 800 to protect this population in the transporting, receiving, compounding, and dispensing of these products. While ACCC’s Oncology Pharmacy Education Network (OPEN) supports USP’s aim to increase personnel safety, we remain concerned that implementation of these proposed standards would result in reduced access to care for patients with cancer.

USP is a scientific nonprofit organization that sets standards for the identity, strength, quality, and purity of medicines, food ingredients, and dietary supplements manufactured, distributed and consumed worldwide.

The guidelines outlined in the proposed Chapter 800 call for any facility compounding or mixing HDs, no matter how infrequently, to undertake a series of precautions, including separate storage locations for sterile and non-sterile drugs. For many ACCC members, adherence to Chapter 800 would not only pose a major financial concern, it would present a challenge in terms of having enough physical space to comply with guidelines—especially for those in urban settings or with facilities located within a cancer center. Ultimately, if the chapter is adopted, it could cause some cancer facilities to either stop offering mixing services for their patients, or in extreme cases, to close altogether.

However, it is important to understand that USP Chapter 800 presents guidelines—states individually adopt Chapter 800 for these to become mandatory. Still, even if a state has already adopted USP Chapter 795 and/or Chapter 797, it does not preclude that state from adopting Chapter 800, as well.  This is because Chapter 800 addresses containment matters and is designed to build on 795 and 797, not replace them.

ACCC’s Oncology Pharmacy Education Network (OPEN) and the Oncology State Society Network (OSSN) recently submitted comments to USP on proposed Chapter 800.  In addition, ACCC joined with representatives from other cancer organizations in a group letter to USP expressing common concerns regarding proposed Chapter 800.

ACCC will continue to keep members informed on this issue.

2015 Proposed Rules: Not So Bad?

Posted in ACCC News, Advocacy, Cancer Care, In and Around Washington, DC by ACCCBuzz on July 15, 2014

By Matt Farber, MA, Director of Provider Economics & Public Policy, ACCC

Centers_for_Medicare_and_Medicaid_Services_logoOn July 3, 2014, the Centers for Medicare & Medicaid Services (CMS) released the 2015 proposed rules for the Hospital Outpatient Prospective Payment System (OPPS)  and the Physician Fee Schedule (PFS), and ACCC is busy poring through the documents in order to get the most pertinent information out to our members as soon as possible.  Look for complete summaries of both rules from ACCC shortly, and ACCC members be sure to dial in to our conference call on the proposed rules on Wednesday, July 23rd at 2 pm ET.

At first glance, we can say the 2015 proposed rules do not appear to include as many drastic changes as in previous years.

For example, the proposed 2014 OPPS rule contained proposals to collapse all E&M codes, package drug administration services, and other packaging proposals, which–had they all been implemented—would have meant significant changes for oncology. In the end, while CMS did finalize the proposal to collapse E&M codes, the agency did not finalize all of the packaging proposals. Now, for 2015, the agency is proposing to increase packaging and composite APCs; however, drug administration is not included in that list. That being said, we know that CMS still wants to study drug administration, so we do not believe that changes to that area are necessarily off the table.

Another interesting proposal for 2015 has to do with off-campus departments of hospital outpatient departments (HOPDs).  Last year, CMS stated that it wanted to collect data to determine if payments made to “off-campus facilities,” often practices that have recently been purchased by a hospital and converted to a HOPD, are justified at different rates.  For 2015, CMS is proposing to require that all services rendered in these off-campus departments be billed with a modifier, so that the agency can study the issue and potentially make changes in the future.

Finally, in the 2015 proposed OPPS rule, drugs are still scheduled to be reimbursed at ASP+6% in the HOPD. So it appears that the ACCC’s years of hard work on this issue have continued to pay off.

On the Physician Fee Schedule side, there is the continuing issue of the sustainable growth rate (SGR)—but this is no surprise. Once again, under this flawed formula, there is a scheduled cut to physician reimbursement of 21%. And once again, this most likely will not go into effect, as Congress will step in later this year or early next year with yet another (hopefully long-term!) “doc fix.” Under the proposed PFS, medical oncology is slated to receive a 1% increase, which is always better than a negative number.  On the other hand, radiation oncology would not fare as well, with larger cuts scheduled for radiation oncology and radiology.

While at first look, it may appear that the 2015 proposed rules put forth less onerous issues than in prior years, ACCC will still be submitting comments to CMS with our concerns, and we encourage you to submit comments as well.  Once ACCC’s comments are completed, ACCC will post them in the Advocacy section of the website, and members can use these as a template, if desired. CMS is accepting comments on these rules until Sept. 2, 2014.

Meanwhile, ACCC encourages all members to join us with your questions on the July 23 members-only conference call.  For more information, please contact Matt Farber at

Will 90-Day Rule Leave Providers Holding the Bag?

Posted in ACCC News, Advocacy, Healthcare Reform, In and Around Washington, DC by ACCCBuzz on May 23, 2014

By Sydney Abbott, JD, Manager, Provider Economics & Public Policy, ACCC

healthcareImplementation of the Affordable Care Act (ACA) is bringing many changes to the healthcare system, including the establishment of health insurance exchanges and new requirements for insurance coverage.

Health insurance exchanges (also known as health insurance marketplaces) provide an option for patients to purchase health insurance outside of employer-based plans and are a step toward the goal of universal coverage. However, because all plans offered through an exchange must meet minimum health benefits and satisfy other insurance reforms, such as a cap on annual benefits and coverage for young adults, individual plan premiums on the exchanges are often more expensive than patients expect. This could lead–and in some cases, has already led–to missed premium payments.

In the event of a lapsed premium payment for individuals enrolled in a federally facilitated exchange (FFE) plan, the ACA gives patients 90 days to become current on any past payments before insurance coverage is terminated. The ACA replaces all existing state laws with the 90 day rule. The rule applies to all consumers, in all states, who purchase subsidized coverage through the FFE health insurance marketplace.

How the 90-Day Rule Works

Here’s how the 90-day grace period works. After the first premium is made, patients have 90 days to pay the next premium. If the patient doesn’t pay the premium for the second month, the insurer can hold all claims. At the end of the third month, if the patient still has not paid, the insurer may terminate the policy.

Unfortunately, there is one wrinkle in the 90-day rule that is concerning for providers. This issue only applies to those individuals who receive tax subsidies to purchase insurance through the FFE insurance marketplace. In this instance, if a consumer still fails to make a payment after 90 days and his or her coverage is dropped, insurers are not required to pay for claims incurred during the last 60 days of the grace period. This means that if coverage for these patients is dropped for nonpayment, physicians must work directly with the patients to collect payments for the balance incurred during days 31-90 of the grace period.

While this issue only applies to individuals who receive tax subsidies to purchase insurance through the federally facilitated insurance exchanges, providers need to know that patients’ insurance cards will not include information on whether or not the patient is receiving subsidies. Claims unpaid the 31st through the 90th day may be pended by the insurer. If the enrollee never pays his or her share, the claim is not payable by the insurer.

Chilling Effect?

During a recent House Energy & Commerce Oversight and Investigations Subcommittee hearing, insurers were asked about health insurance marketplace enrollment and premium payment by enrollees. Representative Michael Burgess (R-TX) and other subcommittee members expressed concern over the 90-day grace period and the chilling effect it may have on provider participation in exchange plans.  Insurance company executives testifying at the hearing assured the subcommittee that adequate systems are in place to give physicians the ability to determine patient payment and eligibility status. Industry representatives said call centers, and in some instances online applications, are available for premium payment verification. However, premium status policies vary by company and so providers and their staff are left with a complex process for determining a patient’s status. At the conclusion of the hearing, the Oversight and Investigations Subcommittee remained concerned that this information is not readily available to healthcare providers  who might ultimately be left unreimbursed for care already provided.

ACCC agrees with the concerns expressed by House Energy and Commerce Subcommittee members and urges Congress and the Administration to work together to require more easily accessible and real-time patient status data to be available to providers. ACCC has submitted a letter to the Administration about this issue and continues to work with members of Congress to raise the volume.  We will keep members posted on any developments on the 90-day grace period.

ACCC Urges Full Coverage of LDCT Screening for Lung Cancer

Posted in ACCC News, Advocacy, Cancer Care, In and Around Washington, DC by ACCCBuzz on May 8, 2014

By Matt Farber, Director of Provider Economics & Public Policy, ACCC

healthcareLast week’s Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) low confidence vote for annual low-dose computed tomography (LDCT) screening for patients at high-risk for lung cancer came as quite a surprise. The Medicare national coverage determination panel’s vote is disappointing in light of the evidence of mortality benefit demonstrated in the National Lung Screening Trial (NLST) and the U.S. Preventive Services Task Force (USPSTF) December 2013 grade “B” recommendation.

The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. The recommendation states that screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. While the Affordable Care Act (ACA) requires private payers to cover services rated highly by the USPSTF, including LDCT, beginning Jan. 1, 2015, the ACA does not mandate the same coverage for Medicare. So providers are awaiting a Medicare national coverage determination (NCD).

ACCC member cancer programs have been following the issue of low-dose CT screening for lung cancer closely. Many community cancer programs have developed or are in the process of developing evidence-based lung screening programs in response to the evidence presented in the NLST study and the USPSTF final recommendation.

ACCC recently submitted comments to the Centers for Medicare & Medicaid Services (CMS) urging full coverage of lung screening for individuals at high risk.

According to media reports, among the MEDCAC panel’s main concerns were the high false-positive rate of CT screening, the potential for LDCT screening to expand beyond the intended high-risk population, and quality issues for scans with low radiation dose. The issues raised by the panel highlight some of the real-world challenges encountered when translating research into practice.

It’s important to keep in mind that Medicare does not have to follow the recommendations of the MEDCAC, so the panel’s recommendation is not the end of the story for LDCT screening coverage. In fact, even if Medicare does agree with the MEDCAC, the public will still have the opportunity to comment on the national coverage decision before a final version is released.

So, while this recommendation is certainly disappointing, it is not the end of the advocacy efforts for ACCC and our members. Stay tuned for the proposed NCD later this year, and more from ACCC. The proposed national coverage determination is due in mid-November, and the public will have 30 days to comment.

ACCC will keep its members updated as this policy evolves. If you have questions or concerns, please contact Matt Farber at


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