Prior Authorization Trends in Radiation Therapy Billing

Posted by Robert Lynch on Oct 16, 2017 8:25:07 PM
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Is your practice experiencing a growing burden from escalating prior authorization requirements?  Probably so.  We recently analyzed our data for multiple radiation oncology billing clients and discovered a significant trend.  Prior authorization requirements have increased each year for the past three years.  The authorization requirements varied considerably by client, but overall authorizations have increased approximately 20% during the past three years.  In 2015 our average client using authorization services, needed prior authorization for 26% of all courses of treatment.  During the same period in 2017 the ratio has grown to 31% of total courses of treatment requiring prior authorization.

Exacerbating the additional burden of attaining authorization for nearly one third of radiation therapy patient encounters is the fact that each payer has different rules and procedures for securing authorization.  The problem has become significant enough for the AMA to lead and recently publish a white paper entitled “Prior Authorization and Utilization Management Reform Principles”.

An excerpt from the white paper reads:

“Utilization management programs, such as prior authorization…., can create significant barriers for patients by delaying the start or continuation of necessary treatment and negatively affecting patient health outcomes. The very manual, time-consuming processes used in these programs burden providers (physician practices, pharmacies and hospitals) and divert valuable resources away from direct patient care.”

The paper identifies 21 principles for utilization management (UM) programs to reduce the negative impact on patients, providers and the health care system.  While we applaud the multi-stakeholder consortium for coming together to draft these 21 principles, we have yet to see much evidence that payers are making significant progress toward applying the principals in a way that reduces the administrative burden of UM programs.

In the meantime, establishing a prior authorization management program is one of the most cost-effective additions you can make to your radiation therapy RCM capabilities.  Whether you use New Bedford’s services or not, you’re likely to realize a significant return on your investments in securing prior authorizations.  With one missed course of therapy possibly costing the average freestanding practice over $10,000, we believe it’s a capability every radiation oncology practice should consider.

If you’d like to learn more about New Bedford’s radiation therapy authorization services, please download our authorization services brochure or contact us for more information.

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Topics: Prior Authorization

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