Insurers eventually approve most denials, though payer-mandated changes may be compromising care
Insurers eventually approve most denials, but payer-mandated changes to the care process could be compromising patient care, experts detailed Wednesday in JAMA Network Open.
Physicians have faced an “increasingly challenging” path to providing care due to prior authorization requirements. Payers often impose these checks and balances to determine whether care is “medically necessary,” sometimes delaying services by “days to even months.”
Memorial Sloan Kettering researchers sought to understand how this plays out in radiation oncology, analyzing a sample of 206 denials from their institution. Of those, 98% eventually led to the delivery of radiation therapy, with average delays of nearly 8 days (and a range from 1 to 49).
“Prior authorization can generate both significant time and financial burdens on physicians and healthcare practices, leading to potentially enormous organizational costs for institutions nationwide,” radiation oncologist Jacob Y. Shin, MD, and colleagues wrote June 12. “In our analysis of cases with insurance-denied RT, almost two-thirds of [radiation therapy] plans were approved on appeal without changes; this requires significant effort from clinician teams,” they added later. “Resources and staff time dedicated to insurance appeals could instead be used to focus on patient-specific care, and cancer centers with limited resources and/or staffing shortages may find themselves under-resourced to make timely appeals.”
The study sample spanned November 2021 to December 2022, with all care provided at the noted New York-based institution. Commercial insurers were involved in most denials at nearly 97%, while the balance (3%) was in Medicare and Advantage plans. Four cases (or 2%) ultimately did not receive authorization, with 3 not undergoing RT and 1 seeking care elsewhere. Of the 206 radiation therapy denials, about 78% were among patients younger than 65.
Payers ultimately authorized 62% of the requests without any change to therapy technique or prescription dose. However, 27% (or 56 cases) were only authorized after modifying the therapy approach or dosing. Of the 21 that required a prescription dose update, the median decrease was 24 Gy (with a range of 2.3 to 51).
“Most insurance denials in radiation oncology were ultimately approved on appeal; however, RT technique and/or effectiveness may be compromised by payer-mandated changes,” the authors concluded. “These findings suggest a clear need for further investigation and action to recognize the time and financial burdens caused by the increasing use of PA by national insurers and the clinical impact of insurance denials on patient treatment and outcome, to establish more optimal ways to authorize and deliver radiation oncology care in a timely and cost-efficient manner, and to investigate for any possible disparities in insurer treatment authorization outcomes.”
Read more including potentially study limitations at the link below.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.