The Long Tail of Radiation Oncology Prior Authorizations

Posted by Robert Lynch on Jan 22, 2020 2:09:00 PM
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We’re often asked: “How quickly can you process prior authorizations?”.  The answer is “it depends”, but we owe our customers a more thoughtful explanation than that, so we’ll try a clarification in this blog.  We’re reluctant to use averages or other statistics that might be misleading, because prior authorization response times tend to occur in what statisticians call a “long tail distribution”.  Some data tend to occur in “normal distributions”.  For example, the average daily high temperature in Virginia in December is about 55oF and rarely falls below 38oF or exceeds 71oF, so knowing the average can be very helpful.


Conversely, our average prior authorization times can be very low (within minutes), but relying on an average can set unrealistic expectations in certain cases, because our data indicates a long tail when all procedures and all payers are considered.  The distribution is defined by the mix of procedures, payers, and clarity of medical guidelines so there are few cases that are average.

For example, if New Bedford is processing a prior authorization for a breast patient with a 3D treatment plan with an electron boost using weekly port film imaging and the total fractions are 28 are fewer, then we have high expectations that we can receive a prior authorization very quickly.  If we’re also fortunate enough to be requesting the prior authorization from a utilization management company that has been provided clear medical guidelines and has implemented an electronic prior authorization request process, then we have high expectations that we’ll receive the prior authorization within minutes.  If we’re working directly with a payer that does not have an electronic adjudication process then the clinical guidelines on prior authorization may not have been as clearly defined, but we’d still be confident we could process the request in 24 to 48 hours.

On the other hand, if we’re processing a prior authorization for a lung patient with an IMRT treatment plan, then we’re almost certain the prior authorization request will go to review.  At a minimum, this will involve New Bedford submitting the patient clinicals to the payer review staff, and likely we’ll need to work with the provider to compare dose distributions and dose volume histograms (DVH) of IMRT versus 3-D conformal treatments (3D-CRT) to ultimately receive the prior authorization.  In the case of an IMRT treatment plan, the payers’ implementation of an electronic process to submit prior authorizations makes little difference.

It’s helpful for your radiation oncology billing service to understand the differences in prior authorization response time expectations and work with the providers and patients to schedule accordingly.  Prior authorizations requirements have increased significantly in radiation oncology and are projected to increase further so having an efficient prior authorization process in place is an increasingly important part of effective practice management.

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Topics: Radiation Oncology Billing, Prior Authorization

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