Centralization of prior authorization services at a community health system's infusion clinics.

Abstract

Purpose: The centralization of prior authorization services to prevent denials and improve reimbursement measures at 2 community hospital-based infusion clinics is described.

Summary: Current process gaps at 2 hospital-based infusion clinics within the health system were leading to a significant denial burden and high out-of-pocket expenses to patients. As a result, authorization and benefit verification processes were centralized by deploying financial coordinators (FCs) at the beginning of fiscal year 2023. A retrospective cohort data review of participating payer claims from adult patients treated at the infusion clinics compared the pre- and postcentralization financial impact. The primary endpoint was the change in the number and cost of denials related to FC workflow. Secondary endpoints included the change in the number and cost of all initial denials, denial type, and success of local denial recovery efforts. Denials related to FC workflow decreased by 68% in the postcentralization period, with a cost reduction of approximately $1.4 million. Total initial denials decreased by 50%, resulting in a cost savings of $3.8 million. Among the top 10 most common denials, 4 were deemed related to FC workflow and declined dramatically after centralization. Local denial recovery efforts resulted in an organizational savings of $0.2 million and a patient savings of $0.19 million.

Conclusion: Centralization of prior authorization services via utilization of FCs significantly reduced the number and cost of preventable denials and positively impacted denial recovery efforts.