Manage Financial Assistance Programs
Learning Objectives
After completing this unit, you’ll be able to:
- Explain the role of financial assistance programs in patient care.
- Describe the data model for financial assistance programs.
- Discuss how to manage financial assistance programs using Life Sciences Cloud.
- Summarize how workflows and automation help you manage financial assistance programs.
Ease Financial Barriers
In the previous unit, you learned how benefits verification helps patients access their benefits. But insurance alone doesn’t guarantee affordability. For many, high out-of-pocket costs stand in the way of starting—or staying on—treatment.
Financial assistance programs bridge this gap by reducing patient costs, but programs aren’t one-size-fits-all. Different programs address different patient needs. Here are the most common types used across the industry.
Program Type |
Description |
For example… |
|---|---|---|
Copay Assistance Programs (CAPs) |
Helps insured patients afford their copays, deductibles, and coinsurance. |
A patient who owes $100 per month for medication may only pay $25 through copay assistance. |
Patient Assistance Programs (PAPs) |
Provides free or discounted medications to uninsured or underinsured patients. |
A patient without insurance receives free monthly medication directly from the manufacturer. |
Quick Start Programs (QSPs) |
Provides temporary free medication while insurance approval or prior authorization is pending. |
A patient who needs immediate access to a drug gets a 30-day supply while their insurance is processing coverage. |
But managing these programs can be tough for many reasons.
-
Complex eligibility rules, where criteria such as income, insurance status, medication type, and regulatory requirements make program setup and enforcement challenging.
-
Fragmented systems, with eligibility checks, approvals, and disbursements scattered across multiple systems make it difficult to track patient status.
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Manual workflows that rely on paper forms, faxes, and call centers, delay approvals and reimbursements.
-
Limited visibility leaves patients and providers without real-time insight into available support options, resulting in missed opportunities for support.
PSP for Life Sciences Cloud removes these inefficiencies by automating eligibility checks, enrollment, and disbursements in a centralized system. Let’s see how Cumulus Pharma uses PSP to support patients like Lisa.
Model Financial Assistance Programs
Behind Lisa’s seamless experience is the structured Financial Assistance Program data model in Life Sciences Cloud. This model organizes key objects and relationships to track eligibility, benefits, and disbursements.
Financial Assistance Framework
First, life sciences organizations model the financial assistance program itself.
This table describes the objects and their relationships.
Object |
Description |
For example… |
|---|---|---|
Program (1) |
Stores key details about financial assistance offerings. |
Cumulus Pharma creates a Diabetes Copay Assistance Program. |
Benefit (2) |
Tracks benefits offered, such as copay discounts or disbursements. |
A $75 monthly copay discount is included as part of the program. |
Benefit Type (3) |
Defines the type of benefit provided. |
The Benefit is defined with a Benefit Type of Copay. |
Program Recommendation Rules (4) |
Establishes criteria for eligibility and recommendations. |
Cumulus defines rules to recommend the program for uninsured or underinsured patients. |
Care Program Assistance (5) |
Links financial assistance programs to care programs and products. |
The Diabetes Copay Program is connected to the Diabetes Management Program and Insulin Product. |
Financial Assistance Enrollment Framework
Once patients like Lisa enroll, dedicated records track their participation, assigned benefits, and disbursements.
This table summarizes these objects and their relationships.
Object |
Description |
For example… |
|---|---|---|
Program Enrollment (1) |
Tracks details of the patient’s enrollment. |
Lisa is enrolled in the Diabetes Copay Assistance Program. |
Benefit Assignment (2) |
Logs assigned benefits for enrollees. |
She’s assigned the $75 monthly copay discount. |
Benefit Disbursement (3) |
Tracks the actual distribution of benefits, like discounts or coupons. |
Each month, Lisa’s discount applies directly to her insulin prescription. |
This framework gives care teams a reliable, real-time view of each patient’s financial support and benefit history.
Use Financial Assistance Programs
Lisa has completed her care benefits verification, but her out-of-pocket costs remain too high, putting her treatment at risk. To ensure affordability, Patient Services Representative (PSR) Lief Hansen checks her eligibility for financial assistance and guides her through the enrollment process.
Check Financial Assistance Eligibility
With PSP for Life Sciences Cloud, you can verify eligibility for financial assistance using different channels. Patients can log in to the patient portal and request direct support. Healthcare providers can check available assistance options through their own portal access. And PSRs like Lief can proactively assess eligibility based on insurance and financial details already on file.
Next up, Lief checks Lisa’s eligibility.
First, he navigates to the Financial Assistance Programs tab on Lisa’s record.
Behind the scenes, a prebuilt Expression Set evaluates her eligibility across multiple programs using configurable criteria like location, insurance type, and income level.
Lisa qualifies for two programs, but PSP automatically recommends the Diabetes Copay Assistance Program, which reduces her out-of-pocket cost from $100 to $25 per month.
Lief confirms the recommendation and proceeds with enrollment.
Submit the Financial Assistance Application
Lief launches the guided application flow, which prepopulates Lisa’s details from her existing records. As the application progresses, the system automatically checks for missing information and flags any required documents, such as proof of income, an insurance verification form, or a signed patient consent. If additional forms are needed, Lisa’s healthcare provider can upload them directly through the provider portal.
After receiving all the documents, Lief reviews the application and submits it for approval.
As Lisa’s application moves forward, PSP for Life Sciences Cloud automates key steps using prebuilt Flows. Click each tab to learn about each flow.
Together, these flows create a smooth, reliable approval process.
For more details on available flows, see Financial Assistance Program Flows in Salesforce Help.
Lief completes the verification checklist and officially enrolls Lisa in the Copay Assistance Program! He updates Lisa on the program details so she knows how to apply her copay benefit when filling her prescription.
Manage Denials and Appeals
In some cases, applications can be denied due to eligibility restrictions or missing information. In this case, PSP for Life Sciences Cloud gives you a streamlined appeals process.
If Lisa’s application is denied, Lief can file an appeal directly from the Financial Assistance tab.
After adding the details, he submits the appeal for review.The case is then routed to a supervisor for approval or further action.
The supervisor reviews the appeal and can approve or deny it directly from Lisa’s record.
Review Assistance History
Once Lisa is enrolled in the Financial Assistance Program, PSP tracks her assistance benefits, providing full visibility into disbursement history and remaining assistance balances.
Lisa and her provider can access this information at any time, bringing transparency and helping them plan next steps confidently.
Thanks to PSP for Life Sciences Cloud, Lisa gets the financial help she needs without administrative delays.
Next, you dive into Outcome Management, where you learn how to track program performance, measure patient success, and optimize financial assistance.