Prior authorization fees in radiation oncology

ARLINGTON, Virginia, October 25, 2021 – The time required to obtain pre-approvals for radiation therapy treatments equates to a financial impact of more than $ 40 million per year for academic medical centers, according to a new study. The results will be presented today at the American Society for Radiation Oncology (ASTRO) Annual Meeting.

Prior authorization is a cost control process used by health insurance companies to determine whether they will cover prescribed medical procedures or medications. Doctors generally need to obtain approval from the insurer before proceeding with the recommended treatment for their patient.

“Prior authorization, while well-intentioned, has become an overwhelming burden on clinics and providers. Our study shows that there is a significant amount of time spent getting cancer treatment approvals from insurance companies, which translates into additional costs for medical centers. Said Brian S. Bingham, MD, chief resident in radiation oncology at Vanderbilt University Medical Center in Nashville and lead author of the study.

Research has shown that barriers to prior authorization are prevalent throughout the U.S. healthcare system. Ninety-four percent of physicians in an American Medical Association (AMA) investigation reported that the process resulted in patient treatment delays, and investigations by ASTRO, AMA and other groups found that the requirements and delays have increased over the past few years. Prior approval requirements are particularly prevalent in radiation oncology; to May 2021 to study Posted in JAMA Health Forum found that radiation oncologists face the highest prior authorization burden of any medical specialty.

While the polls of ASTRO and other groups have estimated the time spent by doctors’ offices with prior authorization, the study by Dr. Bingham’s team is the first to analyze the financial impact of this time in radiation oncology. To do this, they combined compensation data with estimated hours of work to calculate the cost of physicians and staff time spent in the process. They found that compensation costs for prior authorization for treatment totaled approximately $ 40,125,848 for academic radiation oncology practices nationwide.

“The magnitude of the cost was surprising,” said Dr Bingham. “We expected pre-authorization to be onerous, but the degree of expense was telling, especially given how often we go through this tedious process without significant changes to what we have prescribed.” A previous national survey ASTRO-led radiation oncologists found that 86% of approval requests were ultimately approved.

“In our facility, the vast majority of costs do not result in any change in prescribed treatments, which are ultimately determined to be medically necessary. Instead, a patient’s treatment risks being delayed and more expensive due to the process, ”said Dr Bingham.

To arrive at the national estimate, the team first looked at employee time and associated costs within their institution. The researchers compiled an organizational chart of the employees involved in a pre-clearance request and the time each person spent on different stages of the process, such as filling out paperwork, making phone calls, or participating in peer reviews.

Seemingly simple steps like scheduling peer reviews made up the bulk of that time, Dr Bingham said. “Every time someone had to call, the costs went up dramatically, almost four times as much,” he said. “It took longer to coordinate a peer-to-peer discussion than to have the actual peer-to-peer discussion.”

Each year, their department spent nearly $ 500,000 in labor time to obtain prior authorization for radiotherapy treatments. The average claim cost per claim ranged from $ 27.51 for initially approved treatments (63% of all claims) to $ 100.55 when the insurance company required a peer discussion (74% of claims initially denied at the Vanderbilt hospital clinic and 20% of those at satellite clinics).

“Clinics are forced to absorb these costs into their overhead, and it’s time and money that is taken away from other ways we can help patients,” said Dr Bingham. “It made us take a step back and ask ourselves: what can we change? “”

At the institutional level, Dr Bingham said practices may look at their own process maps for managing pre-approvals to look for potential inefficiencies and find ways to improve communication between employees involved in obtaining prior approvals. approvals. He also encouraged Support for the Improving Elderly Access to Health Care Act 2021, which was introduced last week in the US Senate and in May in the House.

“Something has to be done to ease this burden,” he said. “Physician and staff time is a finite resource, and it is being spent in a way that I don’t think anyone considers beneficial for patients or productive for medical teams.”

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Attribution to the American Society for Radiation Oncology (ASTRO) Annual Meeting is required in all covers.

See this study presented:

  • Time-based activity-based costing as a method of estimating the practice-level and national-level financial burden of pre-treatment authorization for academic practice in radiation oncology (Summary 136)
  • Press point: Monday, October 25, 2 p.m. central time. Details here.
  • Scientific Presentation: Wednesday, October 27, 8:00 a.m. Central Time, McCormick Place West, Room 187. Details here; send an email to [email protected] to access it.

ABOUT ASTRO

The American Society for Radiation Oncology (ASTRO) is the world’s largest radiation oncology society, with nearly 10,000 members who are physicians, nurses, biologists, physicists, radiation therapists, dosimetrists, and other health professionals who specialize in treating patients with radiotherapy. . For more information on radiation therapy, visit RTAnswers.org. To learn more about ASTRO, visit our website and follow us on social media.


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