By Chris Dimick
In a cancer patient’s darkest hour, patient navigator Mary Nespor, RHIA, is there to help.
Piloting the complex healthcare system—doctor appointments, medications, insurance forms—can be a daunting task for a patient, especially those facing serious illness.
Whether cancer patients at Saint Francis Medical Center, based in Cape Girardeau, MO, need help appealing an insurance company claim denial or just finding a quiet place to sit after a diagnosis, they turn to Nespor, the facility’s cancer patient advocate.
No day is the same for Nespor, but each day she looks to her HIM education and background for support in helping patients manage their cancer treatment, she says. She attributes her knowledge of healthcare treatment processes and reimbursement inner workings—two areas she must be fluent in—to her HIM background.
The navigator is emerging as a new role in patient advocacy, one that can dovetail well with HIM skills, a point that authors Marsha Dolan, Julie Wolter, and Rachel Heet discuss in a feature story in this month’s print issue (see “Patient Navigators: New Advocacy Role a Good Fit for HIM Professionals”). Most navigator programs are currently within cancer treatment programs.
Nespor has been an HIM director, educator, and consultant, and she has held several roles in the insurance industry, including quality and risk management director at Cigna Healthcare. Each job has given her experience helpful in the wide-ranging duties of her current role.
Nespor is the first and only patient navigator at Saint Francis. The facility has seen positive results from the program since Nespor launched it four years ago, and it is considering expanding the program to other areas of care.
Her duties are driven directly by patients’ needs, but navigators generally offer assistance on a variety of issues related to managing care. Nespor directs all clinical questions to the patient’s doctor, but she helps with just about everything else.
She helps patients compile a list of questions about their cancer for their doctors, and she can help them find a physician on staff that they are comfortable with.
When patients transfer to Saint Francis from other healthcare facilities, Nespor helps ensure the proper medical records are transferred with them. If patients are transferring to the facility from out of the area, she advises them on local support options and extended stay arrangements.
Nespor commonly helps patients find financial assistance for their treatment. She guides them through the necessary forms to receive cancer treatment funding from charities or government assistance, for example, and advises them on their insurance. She has even aided patients in appealing claim denials that prevent them from receiving adequate care.
Nespor’s duties extend to promoting health literacy, such as ensuring patients understand how to take their medications. She makes sure they are connected with their doctors and the facility’s nurse educator to answer their medication questions.
Once the patient feels comfortable with the medication procedure, its financing, and is connected to his or her doctors and nurses, Nespor’s work is done.
“I stay in the process until the docs, nurses, and patients are all fine with me backing out,” she said. “And that makes the patient more comfortable.”
Relying on HIM Experience
Nespor says she relies daily on organization and management skills she learned in her former HIM roles. She leverages the information she learned about the healthcare system as well. Because HIM professionals interact with so many different areas within a facility, a keen HIM staffer can quickly make the transition to a patient navigator, she says.
“HIM people know everything about the industry,” she says.
HIM professionals are familiar with the flow of information through a facility and are good at identifying and resolving workflow problems, skills that can transfer to a patient’s flow through the healthcare system, according to Nespor.
Patient navigators require a general knowledge of the insurance system to help patients understand their insurance claims. But much of what Nespor does, she says, can be learned on the job as long as the navigator has a rich knowledge of the healthcare system and its interlocking mechanics.
Those who enjoy a structured workday, however, should avoid becoming a patient navigator. Duties change frequently and depend on patient needs.
A patient navigator must be ready to work with patients of all ages and be able to manage highly emotional situations. There are times patients will come into Nespor’s office for help immediately following their diagnosis.
“A lot of times when they have just heard the news, and they have never been sick before in their lives, many times that is the first word out of their mouth. They need a little quiet,” Nespor says.
“I’ll speak with them, but I can tell they are not listening, so I keep it just in a reassuring kind of mode. And even if they don’t come up with a question in that little visit, it never fails that they are back. And then we just take it from there. Sometimes they just want basic questions answered, like ‘Where do I go from here?’ or ‘What comes next?’”
The job can be taxing, but Nespor finds it fulfilling. She works with patients that “need the most help they have ever needed in their lives,” she says. The work is important, and seeing people fight and sometimes defeat their illness is inspirational.
Never Give Up
Navigators must have driven personalities, Nespor says. She never wants to give up on helping any patient that steps into her office. Many times, she says, they don’t know where else to turn for help.
One of her greatest successes on the job occurred in 2008 when she assisted a 46-year-old farmer and father of four. The man repeatedly tried to get his health insurance provider to cover treatment for a rare cancer but was denied. The “high dollar” treatment, which involved taking oral chemotherapy drugs, was too expensive for him to pay out of pocket. With his health getting worse, the man turned to Nespor for help. Nespor pored through insurance forms and documents that stacked two inches tall.
“He would say [to me] some days, ‘This is not right. I shouldn’t be taking your time to do this. This is my problem,’” Nespor remembers. “And I would say, ‘No way. This is our problem, because you need the treatment and we are going to get it.’”
After some research, Nespor discovered that the man’s insurer had already paid for an infusion version of the drug he was now seeking in oral tablet form. With this information, Nespor and the patient successfully received preauthorization for the medicine.
It was one of her most rewarding cases. “He and his entire family were very grateful for [my] spearheading that,” she says.
"Helping Patients Navigate Cancer Treatment"
(Journal of AHIMA website),
October 12, 2010.