When Prior Approvals Are "A Game of Chicken"

Mark E. Thompson, MD

Torrie K. Fields, MPH, sees it happen all too often: A provider requests prior authorization (PA) for a treatment and the request is denied, or a request for more documentation sets off another round of delay. In the meantime, a patient who is running out of time is left in the middle of what is essentially a “game of chicken,” Fields said.

She is not a provider—she doesn’t even work in the healthcare system. Fields is a senior program manager for palliative care at Blue Shield of California, where she was recruited to “inject a sense of urgency into the way we take care of people with serious illness and their families.” This involves managing a team with wide latitude to effect changes in the role that Blue Shield plays in the continuum of care.

Often, to eliminate barriers to patient care, Fields finds herself advocating for coverage decisions within the organization. She has seen payers “inadvertently” using their time advantage in a dangerous delay process that makes life tougher for patients grappling with a cancer diagnosis.

Some oncology providers contend that payers have made the payment process more challenging so that they can rein in costs at patients’ expense.

Fields believes that 1 factor behind this trend is the growing complexity of care. “The driver is everyone is needing to cross their T’s and be evidence-based and thinking ‘OK, we have to align with X pathway.’” Sometimes the decision goes against the provider for good reason, she said, but what precedes is a drawn-out process that is painful for all concerned. Fields recalled the case of a patient with brain cancer who got a PA for radiation treatment and was denied that same treatment 2 weeks later; following an appeal and the submission of additional documentation, it became clear that, based on evidence, “they should never have approved it in the first place,” she said.

PA problems have become endemic to oncology, as they have for physicians in other specialties, according to a recent survey (Figure).¹

Occasionally, payers reverse PAs, but there are other PA problems that are significantly more common, according to those interviewed for this article. PA hurdles that lengthen the time, paperwork, and aggravation required to get a patient treated have escalated in recent years, they said.

Figure. AMA Survery Reveals Physician Frustrations with PA Process^a

Mark E. Thompson, MD, past president of the Community Oncology Alliance (COA) and head of its Government Affairs and Policy Committee, said PAs are now required for tests that have long been considered core to sound oncology practice, such as those to determine the genetic risk factor of a patient who has blood coagulation disorders. “I never had trouble ordering these tests. All of a sudden in January, all the big payers decided that this was going to be something they needed [a PA] for, which means more paperwork and going on the computer,” he said. “I get it if somebody doesn’t have a blood disorder. If they want to restrict this test and do [precertification], require it for specialties that don’t do this testing. But this is the meat of what we do. This is one of those things that [are] routine to the practice of hematology/oncology. Don’t make us [obtain a PA] every time. It’s silly.”

Thompson’s practice at the Mark H. Zangmeister Cancer Center in Columbus, Ohio, now has 7 fulltime staffers who spend the workday fulfilling PAs for 17 hematology/oncologist providers. It never used to require that much labor, but each year, Thompson said, the payer community removes more of what oncologists can do without PA.

“Practices all over the country are having to add precertification workers to get this element of the job done. It may be saving payers some money, but it’s hard to fathom how it’s benefiting the health system overall, as the extra expense and time has to come from somewhere,” Thompson said.

Other providers share Thompson’s views. An American Medical Association (AMA) survey conducted last year found that 51% of respondents felt that the PA burden had increased significantly in the past 5 years; 84% indicated that it was high or extremely high; and 54% said that the requirements often or always resulted in care delays.¹ The 27-question web-based survey was administered in December 2017 and drew from a sample of 1000 practicing physicians—40% involved in primary care and 60% in specialty medical posts.

COA’s Government Affairs and Policy Committee is working to formulate a response to the need for faster, more streamlined approvals. This involves maintaining a steady presence on Capitol Hill, Thompson said: “We are working on putting together a group of folks we’re calling the Patient Access to Timely Healthcare Group.”

Commercial payer groups have acknowledged that the PA system has become a burden to physicians and at times may be unnecessarily difficult and frustrating. America’s Health Insurance Plans (AHIP) has joined a collaborative through which they hope to use technology more efficiently, eliminate redundancy, and build evidence-based pathways that reduce the need for a strong gatekeeper presence on the PA side, according to Richard Bankowitz, MD, chief medical officer for AHIP.²

“Payers certainly understand that we don’t want to place needless barriers in the way of patients getting their medications. Payers don’t want to frustrate providers,” Bankowitz said. But the payer community retains a conviction that although PA processes need rightsizing, they play a valuable role in therapeutic management, “especially in areas where there’s a lot of variation in care and where therapy is not being prescribed in an evidence-based manner,” Bankowitz said. This payer initiative has begun with a survey of membership to see how PA is being used and where it can be improved. It was inaugurated in part via a consensus statement issued jointly with the AMA.

The effort may not have the strength to make a difference, according to Thompson. He believes there isn’t enough participation in the collaborative from the provider side, and the panel of stakeholders also lacks enough representation from patient advocates, he said.

It may seem like bureaucracy at times, but the gatekeeper function is vital to the process of good medicine, Bankowitz said: “Providers tend to see [PA] requirements as barriers and as 1 more hoop to jump through. Medical management exists for a reason. It is in the interests of the patients to have safe and effective care.” Cutting it to the extent that some physician groups may prefer would be inappropriate, he said.

Somebody who also has a bird’s-eye view of what’s happening is Bobbi Buell, MBA, principal for Provider Services and Reimbursement Information at onPoint Oncology, a drug reimbursement information services specialist. The calendar year 2017 saw almost 40,000 denials for lack of PAs out of approximately 2.5 million claims made by 2100 physicians who represent 170 practices and clinics that onPoint is tracking. Buell believes that many denials are not clinically based.

Payers appear to be turning down requests without giving full consideration to the patient and provider’s case for a particular regimen. In a recent market research study done by onPoint, almost 80% of practices state that claims have been turned down for lack of a PA even though a PA was obtained. There’s a strategy to this that involves being able to turn down a treatment because “the appropriate paperwork wasn’t there for payers to examine or the right number is not in the right place on the claim,” she said. “The [PA] process may be disjointed between claims processing and medical review in some payer organizations, or we may have to conclude that claims are being denied to delay payment for treatment.”

Thompson contends that many oncology practices have very low payment denial rates—as low as 1% or 2%—but still undergo time-consuming submission routines, which he feels is unnecessary. Payers keep track of provider metrics on PA and therefore should know whom they can trust not to abuse a broader measure of autonomy, and they should not be so hard on providers who stick to evidence-based medicine, he believes. “Precertification should be harnessed to apply to only the outliers in utilization of services, imaging, and pharmaceuticals rather than the blanketed way that this process works in our health system today,” he said.

Buell recommends that providers lessen some of the aggravation by tightening up their own procedures. “Be aware of your state insurance laws relative to prior authorization, denials, and appeals.” Keeping meticulous records on every case is something all should be doing, and rather than resubmit paperwork without real clarification of what’s expected, it’s better to call the payer directly, she added. “First find out why the claim is being denied, and what is needed to solve the problem. Don’t just send the medical record, because what they may need is the pathology report from an outside party. Make sure you are addressing the right problem, and once you address the problem, then make sure that the claim is being paid.”

It’s broadly contended that payers are not making their need for PAs clear enough—that they don’t tell providers what documentation is required. However, Buell said in some cases it may be inexcusable on the part of the practice not to know what a payer expects. Everybody in the practice who handles billing and coding ought to become thoroughly familiar with what the most commonly used payers expect in terms of PA—“the 20% of payers who represent 80% of your claims. You should record what those payers want, and I don’t think everybody is consciencious about that.”

On the other hand, sometimes knowing and recording isn’t enough, Buell conceded. “We just finished talking to a lot of practices about this issue. They feel completely attacked, because no matter what they give payers, they want something else. It seems to be a moving target.”

According to Fields, managing appeals and grievances for rejected PAs once took up half of her average workday. It’s not unusual that rejections are based on not enough information about the case itself or of the appropriate regimen, she said. Compounding the problem: Payers may be required to respond to requests promptly, but that doesn’t mean they have to make a decision, she said. What may follow is simply a request for more clinical information to support the case.

“Most of the discussions I have are with people in my own organization or with clinical staff in my own organization,” Fields said. “What I tell them is ‘This patient is suffering. Even if they have just found out they have cancer, they are suffering.’ What payers need to do is actually publish documentation for what you need to send in the beginning. Patients and providers need to have more transparency into the process.”

Blue Shield gave Fields a broad mandate to effect positive change, Fields said. Having had cancer twice herself, she feels an empathy with patients that drives her in her mission. “You don’t want to prolong fear in a patient’s life,” she said. “Why I joined a payer is to help make things clearer for patients. I feel a deep sense of pride in my organization that we’ve actually reduced the number of these cases happening.”

References

1. 2017 AMA Prior Authorization Physician Survey. AMA website. ama-assn. org/sites/default/files/media-browser/public/arc/prior-auth-2017. pdf. Published March 19, 2018. Accessed April 8, 2018.
2. Health care leaders collaborate to streamline prior authorization and improve timely access to treatment [news release]. Washington, DC: American Hospital Association, America’s Health Insurance Plans, American Pharmacist Association, Blue Cross Blue Shield Association, Medical Group Management Association; January 17, 2018. aha.org/ press-releases/2018-01-17-health-care-leaders-collaborate-streamline- prior-authorization-and. Accessed April 8, 2018.