AAMD Virtual 46th Annual Meeting

AAMD Virtual 46th Annual Meeting

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Understanding Prior Authorization and the Role of a Dosimetrist

L E G I O N H E A LT H C A R E PA R T N E R S

Prior authorization is a utilization management process used by some health insurance companies in the United

States to determine if they will cover a prescribed procedure, service, or medication. The process is intended to

act as a safety and cost‐saving measure although it has received criticism from physicians for being costly and

time‐consuming.

Prior Authorization

Definition provided by Wikipedia https://en.wikipedia.org/wiki/Prior_authorization

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Prior Authorization is a National Dilemma

• The Prior Authorization process was intended to protect patients/members from fraudulent behavior.

• In certain scenarios, it has expanded resulting in harm by delays and unnecessary denials.

• Third party companies have entered the market and their sole goal is to make profit and contain cost.

• Prior authorization – an administrative process used in healthcare for providers to request approval from payers to provide a medical service, prescription, or supply – takes place before a service is rendered.

• Prior authorization is utilization management technique.

• Prior authorization is a cost containment technique.

The Impact of Prior Authorization on our Healthcare System

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A study by Health Affairs further revealed that when the time is converted to dollars, practices spent an average of $55,000 per physician per year interacting with health plans. This equates to $31 billion annually! Prior authorization ultimately ends up costing the health care system more than it saves.

The Impact of Prior Authorization on our Healthcare System

• Deters physicians from requesting the service they want.

• Put more work on hospitals.

• Value based will assist this by removing prior authorization.

• Peer‐to‐peers are not effective.

The administrative burden put on hospitals and physicians (as well as health plans) only increase

the cost of health care in general.

Impact of Prior Authorization on Physicians

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The Impact of PA on our Healthcare System

• 91% care delays due to PA

• 28% serious adverse events

• 75% abandoned treatment due to PA

• 91% (-) impact on clinical outcomes

• 86% high burden on practice

• 88% PA burdens ↑ over past 5 yrs.

• 14.9 hrs (2 BD) per week spent on PA



• 28% serious adverse events

• 75% abandoned treatment due to PA

• 91% (-) impact on clinical outcomes

• 86% high burden on practice

• 88% PA burdens ↑ over past 5 yrs.

• 14.9 hrs (2 BD) per week spent on PA

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• 73% patients concerned about delay

• 32% abandon desired treatment

• 31% average delay >5 days

• 63% hire additional PA staff b/c of burden

• 44% need PA for >50% of patients

>1/3 radiation oncologists use a different treatment because

of delays



• 73% patients concerned about delay

• 32% abandon desired treatment

• 31% average delay >5 days

• 63% hire additional PA staff b/c of burden

• 44% need PA for >50% of patients

>1/3 radiation oncologists use a different treatment because

of delays

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Despite dramatic dosimetric and clinical advantages in many patients, PA is enormous hurdle preventing appropriate access

PA Highly Restrictive in Proton Therapy

“One cannot have radiation induced side effects in tissue

which does not receive radiation”

‐ H. Suit

Proton Therapy Especially Impacted

• Insurance authorization has more of an impact on the decision for proton use than clinically relevant factors.1,2,3

MS Ning and MB Palmer et al. IJROBP 20181

A Shah et al. The Lancet Oncology 2016 2

JE Bekelman et al. IJROBP 2014 3

Gupta et al. IJROBP 2018 4

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• Showing a dosimetric advantage with protons for payer requests is inexplicably associated with higher denials.1







• Showing a dosimetric advantage with protons for payer requests is inexplicably associated with higher denials.1

• Over a 3-year timespan, initial denial rates increased from 55% 74%.4





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Strategic Initiative to Decrease Delays, Denials, and Administrative Costs

We recognized barriers to care and implemented a new operational strategy to:

1. Increase authorizations

2. Reduce delays

3. Reduce administrative costs

Strategic Initiative

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• Most indications are not covered

• Complex authorization and insurance approval process

• Causes Cancellations

• Causes Dual Planning for comparison plans

• Impacts morale

Impact of Prior Authorization and Denials

• Educational needs for RNs on denials process and appeal advocacy

• Burden of P2Ps on MDs/MLPs

• Educational needs for insurance guidelines and processes

• Inefficient denials process resulting in high amount of conversions to photons

• Lows rates of approvals

Summary of Process

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• Defines standard process and streamlines communication about a patient’s status in the workflow.

• Add transparency to the complex proton insurance process.

• Access to every patient’s insurance status at any given time.

• Reduce the chances of the clinical or administrative team receiving conflicting information.

• Effective hand‐off and communication when there is a proton IMRT or IMRT proton conversion.

• Data analysis of bottlenecks or communication gaps.

Workflow Management System

• Education needed for clinicians (MDs, MLPs) on the prior authorization process

• Lengthy LMN creation and review process

• Incomplete or delayed clinical notes

• Ineffective and delayed orders/requests for PBT

• Inefficient process for faxing & FU for authorizations

Opportunities for Improvement Authorization Process

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• Hand‐off to separate team to manage appeals

• P2P scheduling process was ineffective

• Burden of comparison plans on dosimetrists

• Administratively challenging appeal process

• Educational needs to better understand insurance company guidelines

• Clinical and Administrative hand‐off process to IMRT for denied cases

Opportunities for Improvement Denial and Appeal Process

Optimizing the Prior Authorization Process with Dosimetrists

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Proven structure that:

• Reduce the physician administrative burden

• Reduced comparative plans for clinical dosimetry

• Overturned denial rate increased by 56% (75% denial overturn rate)

• Reduced the total authorization time by 40%

• Indirect referrals (internal) referrals increased by +29%

• 34% reduction in personnel costs

Proven Prior Authorization Structure

Certified Medical Dosimetrist

Patient Focus Insurance Focus

Clinical Focus

Reference: Strategic Operational Redesign for Successfully Navigating Prior Authorization Barriers at a Large Volume Proton Therapy Center (JCOP, 2020)

1. Experience/education in clinical oncology, radiobiology, physics, & treatment planning

2. Understand clinical workflow and timelines

3. Understands provider/treatment rationale and interpret/communicate patient benefits

4. Draw parallels between dosimetric advantages and available clinical literature

5. Experience with working closely with Radiation Oncologists

6. In‐depth understanding of comparative plans and how to interpret

7. Radonc billing training and experience

Benefits of CMDs on PA Team

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Educational/Experience ComparisonNurses (RN) vs Medical Dosimetrists (CMD)

Additional Radiation Therapy Specific raining

Courses in common

• CMDs comfortable leaving treatment planning role for administrative position with a focus on clinical background

• Leadership qualities to optimize the entire authorization process with the team

• Extensive insurance training required ‐ terms, guidelines, process, etc.

• Extensive appeal strategy and legalistic appeal letter writing training

• Team structure is important ‐maximize the skill sets of a dosimetrists in this role

CMD as Advanced Practice Dosimetrist

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• Navigate the entire authorization process with a focus on the clinical aspect

• Discuss clinical strategy with physician

• Appeal letter drafting

• Participate/prepare in peer‐to‐peers

• Link clinical workflow with authorization workflow with continuous communication with the clinical teams

• Generate and interpret comparative plan analysis

• Advocacy for patient’s with self‐funded plans

APD Key Responsibilities

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Dosimetry skillsets assist with TDABC models

Divide Division

• Decide how to split up the Division into pieces

• (Clinical Service, Treatment Modality, Diagnosis, etc.)

Plan • Detailed Project Plan with tasks and dates for each of the pieces

Pre work • General Process Map for each piece

Edit Map • Meet with multidisciplinary group of people who do the work and edit process map

Validate Map

• Validate the specific map with the corresponding team

Resources• Assign Labor Resources to each task

Courtesy: Ben Frank, Provision & Nick Olivieri, MDACC

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Optimized Workflow | Prior Authorization Process

Optimized Workflow | Appeal Process

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APD Impact Example

Future Directions

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• Higher participation in physician consults

• Generate comparative plans when requested by InsCo and approved by treating physician

• Involvement in practice development & improvement

• Develop new official training path for Advanced Practice Dosimetrist

• Health Policy [state and federal guidelines]

• Health Economics

• In‐depth Insurance Industry Training

Expansion of Role

• Perfect Position to be Radiation Oncology Physician Assistant

• Clinical Education & Background Foundation

• Technology and trends are changing in RO (SBRT/Hypofractionation, Imaging, Automation, AI)

• Hospitals and Physicians want to reduce their administrative burden (contouring, image review, treatment planning, etc.) to focus on clinical care.

• Insurance burden is increasing for all types of treatments

Advancing the Dosimetry Profession

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• In‐depth insurance industry and health policy training is required

• Training on effective advocacy strategy for appeal letters and P2Ps is required

• Structure of role and prior authorization group is an essential component to capitalize on the CMDs expertise

• Clearly defined workflow and policies and procedures are essential

• The incorporation of CMDs in the prior authorization process positively impacted the center’s operations significantly.

• Advocate for insurance industry recognition of CMDs as part of the RO Care plan.

Conclusions

Contact Information

2001 Kirby Drive, Suite 1100Houston, Texas 77030

LegionHP.com

Matthew B. PalmerPresident & [email protected]

L. Montreal TurnerDirector of Business and Clinical [email protected]

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Documents

AAMD Virtual 46th Annual Meeting