INTRODUCTION

The insurance pre-authorization process for proton therapy can be tedious and often times unnecessarily lengthy. This additional administrative process puts undue stress on the clinical teams, leads to patient dissatisfaction, and requires additional coordination to successfully obtain an authorization.

 

The process of obtaining an authorization is straight forward: you submit your request to the insurance company, they review the request, and then they make a determination.

A majority of these requests result in a denial requiring a significant amount of coordination and management by the authorization team to appeal and ultimately obtain an approval.

METHODS

Retrospective analysis was done of the previous three year’s source data. Over that period, 3,880 pre-authorization requests were submitted for review. The time stamps from authorization submission to approval were reviewed to set a base line for average authorization time, excluding weekends.

 

This time interval is inclusive of the following steps: insurance verification, gathering clinical data, policy review, submission, follow up, and any appeal activity. The data set includes those cases that were approved up front with no denial, and those that required at least one appeal.     

 

RESULTS

The data revealed on average it took ten working days to reach an authorization. Looking deeper into the data, 43% of the cases were approved in three days or less indicating no appeal was needed, and within two weeks 77% of cases were approved.

 

CONCLUSION

Proton therapy is a downstream service. Most of the patients have already received other therapies and the clinical window to get them to treatment is narrow. A significant amount of authorization requests submitted will get approved, but getting an approval in a timely manner is the challenge. Knowing the average time to get an approval (ten days) is a good operational metric when reviewing current workflows or case studies. Prolonged process time might point to errors in submission, procedural issues, or non-compliance to urgent case review timelines by the insurance company.

 

The data also revealed nearly 80% of the approved cases were processing in two weeks or less. Looking at the entire data set you can make some operational assumptions about the process times to obtain an approval: 44% were processed in three days or less, 34% were completed in two weeks or less and the remaining 23% were greater than three weeks.

The MD Anderson Proton Therapy Center has a dedicated team to submit and manage pre-authorization. From an operational standpoint this process is necessary to get patients their prescribed treatments, but requires dedicated staff to keep the process moving. The additional staffing, training and resources are justified given their ability to secure authorizations.

 

Additionally, the dedicated pre-authorization team has taken the burden off the clinic by managing increasing requests for additional data from the reviewers, and increased the efficiencies/accuracy in authorization submissions.

 

Denial rational should be reviewed in detail by subject matter experts. Many times these denials are based on polices that still quote long outdated guidelines or lack current published studies. There can also be a variety of other denial reasons or procedural issues that can be used in appeals documents in support of an approval. Inappropriate denials increase the time to approval and lead to additional appeal steps.