Prior authorization costs radiation oncology clinics more than $40 million each year, study estimates


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According to a new study, the time required to secure pre-approval of radiation therapy treatment is worth more than $ 40 million annually for academic medical centers. The findings will be presented today at the Annual Meeting of the American Society for Radiation Oncology (ASTRO).

Pre-approval is a cost management process used by health insurance companies to determine whether they cover a given insurance policy. Medical procedure Or medicine.Physicians usually need to get insurance company approval before proceeding with patient recommendations process..

“Pre-approval, albeit in good faith, is an overwhelming burden on clinics and healthcare providers. According to our research, a significant amount time Spent to ensure cancer treatment approval from insurance companies. cost Brian S. Bingham, MD, resident at the Vanderbilt University Medical Center in Nashville and the lead author of the study, said.

Studies have shown that Pre-approval Disability is widespread throughout the US healthcare system. In a survey by the American Medical Association (AMA), 94% of physicians reported that this process led to delays in treating patients, and a survey by ASTRO, AMA, and other groups found requirements and delays in the last few years. I found that it was increasing. Pre-approval requirements are especially prevalent in radiation oncology. Study published in May 2021 JAMA Health Forum Radiation oncologists have been found to face the highest pre-approval burden of any specialist.

A study from ASTRO and other groups estimated the time spent on medical practice for pre-approval, but a study by Dr. Bingham’s team found that Economic impact This time it is within the scope of radiation oncology. To that end, they combined compensation data with working hour estimates to calculate the cost of doctor and staff time spent on the process. They found that pre-approval compensation costs associated with treatment totaled an estimated $ 40,125,848 for national academic radiation oncology practices.

“The cost was amazing,” said Dr. Bingham. “We expected pre-approval to be expensive, but the extent of the cost is spectacular, especially given the frequent implementation of this time-consuming process without major changes to the rules. There was something. ”Previous national survey radiation An oncologist led by ASTRO found that 86% of approval requests were finally approved.

“At our facility, most of the cost does not change the prescribed treatment and is ultimately determined to be medically necessary. Instead, the treatment of the patient is due to the process. There is a risk of being late and more expensive. ” Dr. Bingham.

To reach a national estimate, the team first looked at the time and associated costs of employees within the organization. The researchers summarized the flow charts of the employees involved in the prior approval request and the time each person spent on various process steps such as completing paperwork, making phone calls, and participating in peer-to-peer reviews.

Seemingly simple steps, such as scheduling peer-to-peer reviews, accounted for most of this time cost, Dr. Bingham said. “Whenever someone had to answer the phone, the cost went up dramatically — almost four-fold increase,” he said. “It took more time to coordinate the peer-to-peer discussion than the actual peer-to-peer discussion.”

Each year, their department spends about $ 500,000 on employee time, Radiation therapy treatment.. Average compensation costs per request range from $ 27.51 for the first approved treatment (63% of all requests) to $ 100.55 when the insurer requires peer-to-peer discussions (first in Vanderbilt’s hospital-based clinic) It was in the range of 74% of the requests rejected by. 20% of patients in satellite clinics).

“Clinics are forced to absorb these costs into overhead costs, which deprive them of time and money from other ways in which we can help patients,” said Dr. Bingham. “So we took a step back and asked,’What can we change?’”

At the organizational level, practices can look at their own process maps for proactive approval management, look for potential inefficiencies, and find ways to enhance communication between employees involved in ensuring approval. Said. He also encouraged support for a method to improve timely access to care for the elderly in 2021, introduced in the US Senate last week and in the House of Representatives in May.

“We have to do something to reduce this burden,” he said. “Physician and staff time is a limited resource and is spent in ways that no one considers to be beneficial to patients or productive to the medical team.”

Patients’ access to cancer treatment is unnecessarily delayed due to impaired prior approval, findings

For more information:
Aaron L. Schwartz et al, Measuring the scope of the pre-approval policy, JAMA Health Forum (2021). DOI: 10.1001 / jamahealthforum.2021.0859

Quote: Pre-approval requires a radiation oncology clinic of $ 40 million or more each year. The survey estimate (October 25, 2021) was obtained from on October 25, 2021. .html

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