“What am I allowed to do?” radiation oncologist Vivek Kavadi, MD, asked the business manager at Texas Oncology in Sugar Land, Texas.
Kavadi wanted to give his patient with early-stage breast cancer a standard radiation treatment — hypofractionated 3D conformal radiation therapy — following her lumpectomy.
But his hands were tied.
Kavadi had submitted a prior authorization request, but the patient’s health insurance was dragging its feet. And without prior authorization, Kavadi couldn’t schedule his patient’s first treatment.
“I chose the most cost-effective, standard treatment, but nothing could begin without the insurance company’s permission,” he said.
One of the most challenging aspects of the delay was explaining to his patient why he couldn’t schedule her treatment. “We would love to start, but your insurance company has not given us approval. The best I can do is give you a tentative appointment,” he recalled telling her.
After a few days with no word, calls to the insurance company began. “My patient called, I called, my office called,” Kavadi said. “It was a week or more of aggravation, stress and time wasted for my patient and my team.”
This type of delay has become increasingly common in radiation oncology. One recent analysis estimated that 97% of radiation oncology services now require prior authorization under Medicare Advantage. And another analysis found that almost all radiation oncologists said prior authorization delays life-saving care for their patients.
The rise of prior authorization requirements may boil down to the fact that prior authorization is no longer reserved for uncertain or high-cost care. Terrence Cunningham, director of administrative simplification policy for the American Hospital Association, told Medscape last year that “prior authorization used to be applied only to new, costly, or high-risk services,” but now “many insurers require authorizations for even routine care, which is inappropriate.”
The growth of prior authorization requirements has forced many doctors, nurses, and pharmacists to dedicate part of their workday to handling requests and appealing denials and has forced many practices to hire staff exclusively for prior authorizations.
This additional work is costly.
One recent study found that Vanderbilt’s radiation oncology department spent nearly $500,000 annually in employee time to obtain prior authorization for radiation therapy treatments. Extrapolated nationally, the researchers estimated that physicians’ annual compensation for prior authorization duties came to an estimated $46 million. Overall, 86% of these costs were for treatments that were ultimately approved, the majority on initial request and some on appeal.
Kavadi has five full-time employees dedicated to managing prior authorization requests and challenges.
And after a week of delays and hours on the phone with the insurer, his patient’s radiation treatment was ultimately approved.
Kavadi wondered why something so simple needed to be so onerous.
Stretching out an approval for a standard radiation treatment “feels like a means of intentionally delaying care,” Kavadi said. “This is an example of a process that has run so far amok. It’s just a burden across the board.”
And even with his 30 years of experience, “I still have to ask my business supervisor what I am allowed to do,” he said. “I can’t just proceed with what’s best for my patient, what the patient has consented to, and what also happens to be the least expensive option.”
This is part of our Gatekeepers of Care series on issues oncologists and people with cancer face navigating health insurance company requirements. Read more about the series here.
Please email [email protected] to share experiences with prior authorization or other challenges receiving care.
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