Prior Authorization Clinic

Health care costs in the United States are unsustainable. In 2020, health care expenditures rose starkly to $4.1 trillion¹. For years, utilization management techniques have been used to control the cost of care. Though presented in different forms, utilization management seeks to influence decisions about patient care (appropriateness) including drugs, procedures, imaging, etc. Such measures have had both positive and negative consequences, such as enhancing the patient experience, or impacting access to care and contributing to provider burden.

One such utilization management technique is prior authorizations. Health insurance providers (commercial and public) use prior authorization as a method to verify that a treatment (e.g., drug, procedure, or service) is medically necessary before it is done². However, for oncologists and many other providers, the burden of seeking permission to give patients the best care possible, paperwork to fight denials, or the time necessary to educate medical reviewers on why the therapies are needed is too much. And the burden is only increasing.

A recent oncology study found that payer strains with prior authorizations are the most-cited source of provider stress³.

ACCC is developing an educational program titled, “Prior Authorization Clinic,” that will foster discussions on how to ease provider burden and ensure the best quality care for the patient.

The aims of this educational program include:

• Reducing the administrative burden of prior authorization processes by sharing best practices
• Addressing key areas of prior authorization, including new technologies or areas where there are high errors in billing and coding resulting in high denials
• Providing examples of standardized criteria for ordering and prescribing services that align with evidence-based guidelines
• Developing a series of case-based prior authorization scenarios that cancer programs can utilize in advocating for change, locally and nationally, at their cancer program
• Showcasing successful methods to track prior authorizations and results for pertinent members of the multidisciplinary cancer care team

“As a community-based cancer center, a lot of our patients deal with financial toxicity, and do not have access to certain medications or funds. We are currently trying to define how to stretch expertise and resources to manage patients across all sites as efficiently as possible.”
Andre Harvin, PharmD, MS
Cone Health

“As a clinician, I am really concerned about getting treatment delivered to patients in a timely fashion, and in a way where they feel confident in the system and that all the resources have been obtained.”
Richard Ingram, MD
Shenandoah Oncology

“From a psychosocial perspective, we hear and deal with a lot of clients when they receive a denial, and even when they just start the process with health literacy issues.”
Vilmarie Rodriguez, LCSW
CancerCare

References

1. Centers for Medicare & Medicaid Services. National Health Expenditure Data: Historical. 2021. Retrieved July 14, 2022, from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical#:~:text=U.S.%20health%20care%20spending%20grew,For%20additional%20information%2C%20see%20below.
2. American Cancer Society. Getting Medical Pre-approval or Prior Authorization. 2019. Retrieved July 14, 2022, from https://www.cancer.org/treatment/finding-and-paying-for-treatment/managing-health-insurance/getting-medical-pre-approval-or-prior-authorization.html
3. Kirkwood, M.K., Hanley, A., Bruinooge, S.S., Garrett-Mayer, E., Levit, L.A., Schenkel, C., Seid, J.E., Polite, B.N., & Schilsky, R.L. The State of Oncology Practice in America, 2018: Results of the ASCO Practice Census Survey. Journal of Oncology Practice 2018 14:7, e412-e420