An analysis of prior authorizations for imaging studies demonstrated that most were unnecessary, resulting in potential delays in care and administrative burden for health care providers. These findings were presented at the 2019 American Society of Clinical Oncology (ASCO) Quality Care Symposium held in San Diego, California.1

“While prior authorizations are intended to ensure medical necessity, these additional requirements can add to administrative burden,” explained lead author Mallika Sharma, MPH, a quality and value analyst at Seattle Cancer Care Alliance (SCCA). “In some cases, the process can even cause significant delays for patients, increasing their anxiety and diminishing quality of life.”2

This study evaluated the outcome of prior authorization submissions for imaging studies from a health care system to commercial payers.

Researchers at SCCA found that 94.8% of prior authorizations for imaging studies requested by health care providers within that health care system were approved, although additional documentation was needed in some cases.

Despite the high overall approval rate, with only 2.46% of overall submissions culminating in a denial, 2.15% of submissions were approved following a long delay, adding to significant administrative burden and a delay in care. Of those imaging studies deemed to not meet medical necessity criteria, most were related to use of PET/CT imaging.

Based on the results of this assessment, an agreement was reached between SCCA and a large commercial payer to eliminate the need for prior authorizations for all imaging studies, with the exception of PET and PET/CT imaging. The agreement was contingent on all ordering health care providers completing training on the NCCN Imaging Appropriate Use Criteria.

Subsequent quarterly audits conducted at SCCA showed that health care providers’ rates of training completion and adherence to NCCN guideline recommendations related to imaging were both 100%.

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“A strong partnership and shared vision with a payor enabled us to eliminate wasteful prior-authorizations,” explained the study presenters. “Our high training completion rate and compliance rate implies strong support from our providers and leadership to provide value-based care to our patients.”1

In this context, Tracy Wong, MBA, noted that “most [electronic health records] have the capability to embed clinical decision support that aligns with payers’ medical coverage policies, making this a relatively simple and scalable way to speed and improve care. This is what payers’ are asking for: the ability for health care providers to access the most up-to-date, evidence-based practice guidelines in real time.”2

References

1. Sharma M, Gustafson A, Jagels B, et al. Collaboration with commercial payor to eliminate prior authorization. J Clin Oncol. 2019;37(suppl 27):abstr 9 2. ASCO. Studies highlight barriers of drug costs and prior authorizations [news release]. Alexandria, VA; September 3, 2019. https://www.asco.org/about-asco/press-center/news-releases/studies-highlight-barriers-drug-costs-and-prior-authorizations. Accessed September 10, 2019.