Prior authorizations (PAs) in radiation oncology have grown over 20% in the past few years and more and more providers are having difficulty keeping up with the administrative burden of managing the PA process. Often in radiation oncology, there is a practice administrator who might also be tasked with processing PAs. However, managing PAs on a part time basis has become increasingly more difficult because each health plan may implement different requirements and clinical guidelines may change with a surprising frequency. It is becoming more common for larger practices to allocate a dedicated staff member to manage all prior authorizations. Appointing a specialist dedicated to the task allows that position to be more knowledgeable about each payer’s unique requirements and processes. Other advantages include:
- Starting Quickly. Payers typically claim to have up to two weeks to respond to a PA request so it’s important to start quickly. Staff members focused exclusively on PAs can monitor simulation schedules and consults and compare to known medical guidelines for PAs to quickly determine which patients will need a prior authorization and initiate the request as soon as possible.
- Monitor Progress and Resolve Delays. A PA specialist can ensure that all prior authorization requests are tracked and monitored so that no surprises occur that might delay patient treatment. Often PAs can be expedited if the PA specialist knows the right procedures for escalating the urgency for each payer.
- Prioritize: A PA specialist can triage prior authorization requests and allocate time to the inevitable priorities such as when a patient is scheduled for IMRT or for treatment the day after simulation.
- Gain efficiencies. Specialization and repetition allows the practice to invest in tools that help make the prior authorization staff more efficient. Tools such as a workflow management system that identifies next steps and projects potential delays can be instrumental in securing prior authorizations in a timely manner.
In addition to all the benefits above, we’ve observed that employees are much more efficient and content when able to focus on a more defined set of tasks and manage them well, rather than having to constantly switch between PA requests and other practice management activities.
Gloria Mark, professor in the Department of Informatics at the University of California, Irvine, says that when people are interrupted, it typically takes 23 minutes and 15 seconds to return to their work, and most people will do two intervening tasks before going back to their original project.
With many trends in healthcare indicating that PA requirements will increase, now may be the time for radiation oncology practices to reevaluate staffing plans for PAs. A recent ACCC study reflected 82% of respondents reported that prior authorizations requirements had either “significantly increased” or “slightly increased”. New Bedford projects that payment reform from volume to value will continue to substantially increase the use of utilization management programs especially for high cost / risk patients and continue to drive the need for a disciplined and organized radiation oncology prior authorization process focused on generating quality outcomes.