In:
Journal of Clinical Oncology, American Society of Clinical Oncology (ASCO), Vol. 37, No. 27_suppl ( 2019-09-20), p. 9-9
Abstract:
9 Background: For commercial insurance plans, there is often a requirement to obtain prior-authorization for specific services. Prior-authorization though intended to ensure medical necessity, can cause significant delays in patient care and create an unnecessary administrative burden. It often leads to undue anxiety in patients, dissatisfaction among providers and substantial waste in the system. To increase our efficiency and improve patient and provider experience, we partnered with one of our region’s largest commercial payors to eliminate prior-authorization. Methods: A Lean Six-sigma DMAIC approach was adopted: Define- created a process map. Measure- calculated baseline for prior-authorization denials. Analyze- conducted retrospective analysis to identify areas to improve. Improve- conducted provider training for appropriate imaging guidelines. Control- established internal auditing to check provider compliance. Results: At SCCA, we found that 94.8% of prior-authorizations were approved instantly or after providing more documentation, thus prior-authorization did not add value. Moreover, 2.15% were approved after peer-to-peer review that involves significant administrative burden and delay in care. Only 3% prior-authorizations did not meet medical necessity criteria, major reasons being- PET/CT and CT CAP ordered in combination, or PET/CT ordered without clear justification. 2.46% prior-authorizations led to a patient receiving a letter of denial. SCCA and the payor agreed to eliminate prior-authorizations for all imaging (except PET and PET/CT). This required all ordering providers to attest to completion of training on the NCCN Imaging Appropriate Use Criteria. In addition, a quarterly internal audit was put in place to check provider compliance to NCCN guidelines for ordering Imaging tests. SCCA achieved a 100% provider training completion rate and 100% provider compliance to NCCN guidelines in the first two internal audits. Conclusions: A strong partnership and shared vision with a payor enabled us to eliminate wasteful prior-authorizations. Our high training completion rate and compliance rate implies strong support from our providers and leadership to provide value-based care to our patients.
Type of Medium:
Online Resource
ISSN:
0732-183X
,
1527-7755
DOI:
10.1200/JCO.2019.37.27_suppl.9
Language:
English
Publisher:
American Society of Clinical Oncology (ASCO)
Publication Date:
2019
detail.hit.zdb_id:
2005181-5
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