New Bedford Corporation has been reporting on the growing frequency of radiation oncology prior authorizations. Although we’re well aware of the growing scrutiny and the need to submit medical records to gain approval for certain courses of treatment, we never imagined an Aetna medical director would admit to never reviewing medical records during nearly three years of making coverage decisions.
In this news link, CNN reports on the case. Although the case is not about radiation oncology specifically, it’s an alarming read because the medical director who signed the denial of coverage determination acknowledges that he never reviewed the medical records. Aetna defended the medical director, saying in its legal brief that he relied on his "years of experience" as a trained physician in making his decision and that he was following Aetna's Clinical Policy Bulletin appropriately.
New Bedford submits numerous medical records to Aetna in support of radiation oncology authorizations. Although our experience has been generally positive, we believe the article about Aetna is indicative of a growing concern. As more and more prior authorization requirements are imposed, there is a growing need for the payers to retain staff who have the medical background and knowledge to make informed decisions on the supporting medical documentation. Clinical pathways are not so clearly defined that every case can either be approved or denied based on the diagnosis and procedure codes.
Contact New Bedford today to learn more about how we can help with prior authorizations. Our staff can help identify which courses of treatment will fall within the clinical guidelines and which are surely to be challenged by the payers.
