Prior auth complaint request :)

[deleted1111261]

Evicore's exact logic with their treatment guidelines. Which could go farther and like I said mandate single fraction only, prostate hypofrac only, etc. Of course we all understand the insurance side of it. There's the physician and patient side of it too.

I can’t speak for evicore

I can say that if Astro and NCCN say yes or no to something, that’s a reasonable / usual & customary treatment option.

I can’t speak for creating internal, more restrictive guidelines. I don’t do that.

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[temujim]

If one is going to differentiate between treatment techniques available and to choose more effective ones, if there are contracted facilities that you deem as equal, why should the payor pay full freight for the more expensive one?

I'm not dictating care or where a patient should get it. I'm just trying to think through this idea of never steering and always allowing patients to choose the highest cost treatment, when there is little to suggest there is value for the additional cost.

Imagine a world where everything is Anderson-ized, there are no low cost centers left, and PA is out of control because costs are now 2-3x. There is zero competitive advantage for having lower prices, b/c there is zero skin in the game. The employers should care, as most/many of them are actually shouldering the costs. There is this unbridled anger at payors, but many times the payor is acting as the benefits administrator and the employer is the one wanting to reduce costs.

We claim to value community medicine, community doctors, community care. Even when the community option is excellent and low cost, the larger centers still want to take as much market share as possible. This is fine, if the playing field was equal. But, it is not level at all. And, in my view, this make medical care much more expensive than it needs to be.

My understanding is the insurance company doesn't really mind the higher prices in the contracting phase -- this cost is all factored in the premiums that are then charged to employers/institutions/individuals. If anything it provides a fat spread in the actuarial calcs. On the back end then there is a significant incentive to withhold payments with delays or denials.

There is a value to community care. However from a large insurance or governmental perspective it is far easier to control a small group of players. And whether intended or unintended that's the result of the last 50+ years.

 

[OTN]

If one is going to differentiate between treatment techniques available and to choose more effective ones, if there are contracted facilities that you deem as equal, why should the payor pay full freight for the more expensive one?

I'm not dictating care or where a patient should get it. I'm just trying to think through this idea of never steering and always allowing patients to choose the highest cost treatment, when there is little to suggest there is value for the additional cost.

Imagine a world where everything is Anderson-ized, there are no low cost centers left, and PA is out of control because costs are now 2-3x. There is zero competitive advantage for having lower prices, b/c there is zero skin in the game. The employers should care, as most/many of them are actually shouldering the costs. There is this unbridled anger at payors, but many times the payor is acting as the benefits administrator and the employer is the one wanting to reduce costs.

We claim to value community medicine, community doctors, community care. Even when the community option is excellent and low cost, the larger centers still want to take as much market share as possible. This is fine, if the playing field was equal. But, it is not level at all. And, in my view, this make medical care much more expensive than it needs to be.

No one in radiation oncology leadership seriously claims to value community care. I would claim the precise opposite. UPenn Palliative Network, etc.

 

[TheWallnerus]

No one in radiation oncology leadership seriously claims to value community care. I would claim the precise opposite. UPenn Palliative Network, etc.

In the pantheon of insulting radiation articles (if an article can be insulting) that one was up there

 

[MidwestRadOnc]

I think they can't handle the cognitive dissonance of being a doctor and hurting patients for money, nor should they.

This is the most pertinent comment in this thread.

Just found out that UHC routinely denies IMRT for SCLC, but not NSCLC. The rationale for this is ??? IMRT matters for sparing normal tissue for the exact same plan but different histology because ??? Actively harming patients for money. Yes. Any radonc profiting from this is a disgrace.

 

[A_DeMichele]

Our therapists are barred by admin
from turning on the machine unless auth is obtained, and dosimetry won't finalize a plan either, so pretty much nothing is going to happen without an insurance pre-auth, and the reviewers know it. I think they can't handle the cognitive dissonance of being a doctor and hurting patients for money, nor should they.

You could literally be the world's leading expert in a disease and have the best quality equipment, an outstanding team, doing absolutely what the patient needs, with guideline support. And yet, the patient's care still gets decided by a retiree or forced- out former physician who doesn't know what the heck they're even talking about, who is literally just reading off a page from a coverage policy written years ago to serve an insurance company's own selfish needs.

No difficulty at all for docs doing PA.
It is the attending that is insisting on SBRT (protons, etc) who is hurting the patient (by delaying the start).
There is nothing that SBRT can do but IMRT or 3D-IGRT can't.

 

[IonsAreOurFuture]

No difficulty at all for docs doing PA.
It is the attending that is insisting on SBRT (protons, etc) who is hurting the patient (by delaying the start).
There is nothing that SBRT can do but IMRT or 3D-IGRT can't.

I think we know who is delaying the start. Patients who are not subjected to prior auth are not delayed at all, and actually get the care they need, when they need it.

PS, when was the last time you actually prescribed 12 Gy x 4 fx for a lung primary and called it anything other than SBRT? Really, in which decade and which country?

Why not continue the "3D is as good as SBRT" farce and require that since linac-based therapy has never been shown superior to cobalt-60 in a randomized trial, only 2D cobalt plans should be approved going forward? We need someone to champion against the missing evidence base for linacs as a whole and take on "Big Linac"

 

[deleted1111261]

Just wanted to thank all of you for very insightful comments and discussion.

I had a wonderful meeting and I think we can do more to make things better across the board.

We are all suffering, patients more so. It has got to improve.

Hopefully, we can make some effective changes to improve the process meaningfully.

 

[Neuronix]

My prior auth annoyances lately have been two patients who are hospice-bound with painful bone metastases who could use quick and focal palliation with 8 Gy x 1 fraction prior to hospice.

Patient and family aren't willing to wait more than a small number of days, and when hiccups with auth happen, patient just goes to hospice.

Insurance's bottom line won twice here recently. Due to insurance delay patients went to hospice, and no palliative RT was given. Cheaper for them I guess. Crank up the opioids.

 

[MidwestRadOnc]

My prior auth annoyances lately have been two patients who are hospice-bound with painful bone metastases who could use quick and focal palliation with 8 Gy x 1 fraction prior to hospice.

Patient and family aren't willing to wait more than a small number of days, and when hiccups with auth happen, patient just goes to hospice.

Insurance's bottom line won twice here recently. Due to insurance delay patients went to hospice, and no palliative RT was given. Cheaper for them I guess. Crank up the opioids.

This is one where you just treat anyway.
See sim and treat same day. You lose some codes by doing that and may not ultimately get paid. I did one a few months ago like this because I knew the patient wasn’t coming back for sim another day. Beam on 2 hours from consult, went to hospice next day, got a report a few days later their pain resolved.

 

[drowsy12]

This is one where you just treat anyway.
See sim and treat same day. You lose some codes by doing that and may not ultimately get paid. I did one a few months ago like this because I knew the patient wasn’t coming back for sim another day. Beam on 2 hours from consult, went to hospice next day, got a report a few days later their pain resolved.

Fully agree

Don’t quite understand a situation in which an Institutuon would wait to treat a straight forward 8/1 bone met. There’s no need for PA, there’s no risk of not getting paid. It’s a standard of care cheap treatment

 

[MidwestRadOnc]

Fully agree

Don’t quite understand a situation in which an Institutuon would wait to treat a straight forward 8/1 bone met. There’s no need for PA, there’s no risk of not getting paid. It’s a standard of care cheap treatment

UHC I believe will refuse retroactive payments. Someone correct me if I’m wrong. There’s one company that will. If you treat without PA they will never pay you. Still you treat anyway because it’s the right thing to do.

From and admin perspective this boils down to how your staff are paid. If you are paying dosi per plan and the doctor per RVU then yeah I guess it’s a small hit. If everyone is salary then ???

 

[Neuronix]

Hmmm... Good point, I suppose I could have just done it anyway and hoped insurance would pay.

My institution isn't happy with that, but they're not heartless, and in retrospect I could have pressed for an exception to the policy. I worry too about patients ending up getting billed by the health system if insurance denies or having to fight some battle between insurance and the health system. Of course if the patient dies the debt will likely be discharged. Or as one deceased patient's family member told the billing office: "if you want the money you'll have to call Jesus."

Still I hope the point still stands that prior auth is harming these patients for short, cheap, courses of palliative RT.

 

[evilbooyaa]

Fully agree

Don’t quite understand a situation in which an Institutuon would wait to treat a straight forward 8/1 bone met. There’s no need for PA, there’s no risk of not getting paid. It’s a standard of care cheap treatment

The concern is that the insitution goes after the patient for the cost of the treatment. Rad Oncs are mere pawns and unable to stop the hospital industrial complex from going after a patient without either insurance pre-approval, or institutional pre-approval. Nobody wants to bend.