Redesign of a prior authorization process at a proton therapy center was associated with an expedited appeals process, according to results of a study published in JCO Oncology Practice.
Prior authorization is a management process instituted by health insurance companies whereby certain prescribed procedures, services, or medications must be pre-approved by the payor prior to their implementation to ensure coverage.
Although the purpose of prior authorization is to prevent patient exposure to inappropriate interventions, concerns have been raised that it may be associated with unnecessary delays in the timely delivery of particular treatments, such as proton beam therapy (PBT).
In 2017, with the goal of expediting the authorization process for PBT, a single proton therapy center launched an initiative that involved restructuring its internal team. The changes included replacing the historical administrative staff with clinical medical dosimetrists, who are uniquely trained in radiation oncology.
In this administrative role, the advanced practice dosimetrists independently pursued authorization rebuttals and directly helped relevant stakeholders navigate the multilayered authorization process, thus reducing the burden of administrative tasks on clinical teams, explained the study authors.
In addition, the previous authorization process team manager was replaced by “a medical executive with extensive firsthand experience in the insurance authorization process,” and an automated electronic system was put in place for the purpose of tracking steps in the authorization process.
During an 18-month period between October 2016 and March 2018, 1700 patients were involved in the authorization process for proton therapy at the center. Although 1266 (74%) of these patients ultimately received approval for PBT, 633 were initially denied insurance coverage for the procedure. Of these, appeals were entered for 454 patients, with 199 of the denials being reversed.
To evaluate the impact of the restructured team on the prior authorization process, comparisons were made of specific metrics associated with 6-month periods corresponding to pre-restructuring (October 2016 to March 2017) and post-restructuring (October 2017 to March 2018) of the authorization team.
A key finding was a significant reduction in the median time of post-appeal approval from 30 days during the pre-restructuring period to 18 days during the post-restructuring period (P <.001). In addition, the rates of overturned denials and internal referrals increased by 56% and 29%, respectively, following the restructuring of the authorization team. Furthermore, a 37% increase in the rate of patients starting PBT for the first time was observed during the post- compared with the pre-restructuring period.
Of note, an analysis of costs related to the restructured authorization team, as well as associated outcomes regarding approvals for PBT, led the study authors to estimate that the cost of the redesigned prior authorization team would be justified in 5 to 6 months (despite phase-in).
“The concepts underlying our operational redesign may be implemented among other oncologic practice settings, for novel systemic therapies or technologically advanced surgical methods, to facilitate efficient navigation through the [prior authorization] process and promote timely access to evidence-based cancer therapy,” concluded the study authors.
Brooks ED, Ning MS, Palmer MB, et al. Strategic operational redesign for successfully navigating prior authorization barriers at a large-volume proton therapy center. JCO Oncol Pract. Published online July 8, 2020.doi:10.1200/JOP.19.00533