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:
“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
Improving the Prior Authorization Process
With ever increasing payer strains, how can the prior authorization process be improved? In this resource, three focus groups discussed barriers and challenges they regularly experience, and subsequently, generated potential solutions to help overcome these mounting strains. Read what they uncovered and learn what measures you may take now.
Impact of Prior Authorizations Beyond Health Insurer Cost Savings
Prior authorizations are a burden to timely health care delivery. ACCC has put together a resource to help you maximize efficiency.
Healthcare contracts often contain complicated provisions that can delay patient care. This resource lists ten considerations healthcare teams should keep in mind when negotiating contracts with insurance payers.
Learn more about how to navigate these specific challenges by viewing the on-demand webinars in this informative six-part series, titled: "Proactive Interventions for the Prior Authorization Process."
In the first webinar, we will hear from Sarah Hudson-DiSalle, PharmD, Rph, Pharmacy Manager, from The James Cancer Hospital, and Jordan Karwedsky, Financial Counselor from Green Bay Oncology. In this webinar, we discuss ACCC Prior Authorization Focus Group findings, payer recommendations, and how to best prepare for the prior authorization "blizzard" for next year.
In the second webinar, we will hear from Andre D. Harvin, PharmD, MS, Executive Director of Pharmacy for Oncology at Cone Health. We will discuss how your pharmacy team can be a major ally and support in obtaining prior authorizations, help navigate biosimilar changes, and address medical necessity.
In the third webinar, we will hear from Jennifer Paquet, RN, BSN, Financial Assistance Patient Care Coordinator Supervisor from Bassett Cancer Institute and Aimee Hoch, MSW, LSW, Oncology Financial Navigator from Grand View Health Cancer Center. We will discuss barriers to radiology prior authorizations and provide insights on how to address them.
In the fourth webinar, we will hear from Gretchen Van Dyck, Financial Counselor from St. Vincent Hospital Regional Cancer Center and Rachelle Gill, Program/Department Coordinator II for Proton Therapy Appeals at Fred Hutchinson Cancer Center. Join us as we discuss radiation authorization submissions before treatment and strategies on how to work radiation authorization denials and appeals after treatment.
In the fifth webinar, we will hear from Angie Santiago, CRCS, Manager of Oncology Financial Advocacy, Sidney Kimmel Cancer Center at the Thomas Jefferson University Health System, and Chair of ACCC’s Financial Advocacy Network, and Sarah Shaw, Oncology Program Manager at St. Luke’s Cancer Institute in Boise, ID. Join us as we discuss importance of medical necessity in oncology and how clear denial data can help maximize reimbursement.
In this final webinar, hear from our experts Jordan Karwedsky, Financial Counselor, Green Bay Oncology, Wendi Waugh, BS, RT(R)(T), CMD, CRT, Administrative Director of SOMC Cancer Services & Ambulatory Infusion, Southern Ohio Medical Center, and Dr. Michael R. Gieske, Director of Lung Cancer Screening. Join us as we discuss prior authorization challenges in biomarker testing, importance of providing access to biomarker testing for underserved populations, how biomarkers are shaping the future of medicine, as well as what can be done at the policy level to allow for more access.
This project is made possible by support from: Amgen, Genentech and Seagen
