The Burden of Insurance Prior Authorization on Cancer Care: A Review of Evidence From Radiation Oncology

Purpose

Despite its high cost-effectiveness, radiation oncology faces the greatest prior authorization (PA) burden of any medical specialty. Insurance denials and resulting treatment delays have been documented across several treatment modalities, including stereotactic body radiation, intensity modulated radiation, and proton therapy. Although insurance companies suggest that PA is intended to control health care spending and ensure the implementation of evidence-based practice, the number of radiation treatment plans reviewed by the PA process that result in changes is quite low. Yet, the cost to patients, providers, and the health care system is rising.

The increased administrative work required to address the appeal process, including the development of radiation plan comparisons, results in lost productivity of radiation staff and increased clinic costs that are not currently reimbursed. Treatment delays from PA may elevate patient anxiety and affect their ability to enroll in clinical trials, resulting in decreased quality of care. As a result of possible harm to patients, the Centers for Medicare and Medicaid Services developed a ruling that mandates increased transparency of insurers’ requirements, decreased allowable time for arriving at PA decisions, and a more efficient electronic communication system to address the time and resource burden of PA.

Methods and Materials

This article summarizes key discussions from the literature and provides recommendations to help mitigate insurance PA strain.

Results

These recommendations broadly address the following key areas: (1) omission of PA for routine care and clinical trials, (2) implementation of efficient, streamlined electronic peer-to-peer communication, (3) increased transparency of insurance requirements and rationale for denials, and (4) decreased time allowances for PA decisions.

Conclusions

Policy reform focused on evidence-driven treatment coverage, reduction of the proportion of cases requiring PA, and a simplified, timely insurance appeal process is necessary to ensure optimal cancer care for patients requiring radiation therapy as part of their cancer journey.