Prior authorization: biggest problem small radiation oncology practices are facing

[deleted956486]

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Write your representatives to fix prior authorization. I know how much trouble it causes the little guy in the community. It's not like the real agenda is approval for protons or MRI viewray nonsense. Its helping small businesses. Please help. Forget about residency expansion. That's not real. This is. Stop everything you are doing and call your representative.

 

[xrthopeful]

what exactly is your problem with this? I'm missing the issue?

Prior authorization for RT utilization has gone HAM. especially with Evicore. They're hiring plenty of retired rad oncs to make lives harder for the rest of us working.

 

[OTN]

I for one have zero problem with ASTRO trying to help with prior auth.

 

[medgator]

I for one have zero problem with ASTRO trying to help with prior auth.

Agree, better than some of the issues they've focused on in the past.

Insurance auth guidelines are essentially ways to cost contain, and only are evidence-based when the evidence supports cheaper/lower cost treatment

 

[Gfunk6]

They're hiring plenty of retired rad oncs to make lives harder for the rest of us working.

They are hiring plenty of full-time, practicing ROs as well! Works out well for ROs who need supplemental income and believe me that number will increase in the months to come.

 

[medgator]

They are hiring plenty of full-time, practicing ROs as well! Works out well for ROs who need supplemental income and believe me that number will increase in the months to come.

I have definitely spoken to practicing ROs for p2p calls for igrt/imrt approvals (not through evicore, but other prior authorization companies), and I suspect they do the work for the exact reason you mention.... Supplemental income

 

[Reaganite]

OMG, don't get me started on this. Could go on and on about all the **** I've dealt with, particularly this year. The PPOs have gone insane in my area with their pre-auth games. We call the insurance to request pre-auth, are told we don't need it for the diagnosis code, then receive denials of payment for not having pre-auth. Of course, the insurance won't give us any feedback until end of treatment, so we don't even get a denial until several weeks after patient is done. We will call two different departments in the insurance company and one operator tells us pre-auth needed, the other says no need. We've even had them on 3 way calls giving us conflicting information. UM dept says no pre-auth, but claims dept on same call says it's needed. I stopped listening to the operators and UM dept and go directly to the websites. If the website says preauth required for IMRT, I refuse to treat patient until I have one. I make patient call as well. If I verify no preauth needed on website I still ask for a pre-determination. I also started just reflexively doing 3D vs. IMRT planning comparisons on all cases.

 

[medgator]

OMG, don't get me started on this. Could go on and on about all the **** I've dealt with, particularly this year. The PPOs have gone insane in my area with their pre-auth games. We call the insurance to request pre-auth, are told we don't need it for the diagnosis code, then receive denials of payment for not having pre-auth. Of course, the insurance won't give us any feedback until end of treatment, so we don't even get a denial until several weeks after patient is done. We will call two different departments in the insurance company and one operator tells us pre-auth needed, the other says no need. We've even had them on 3 way calls giving us conflicting information. UM dept says no pre-auth, but claims dept on same call says it's needed. I stopped listening to the operators and UM dept and go directly to the websites. If the website says preauth required for IMRT, I refuse to treat patient until I have one. I make patient call as well. If I verify no preauth needed on website I still ask for a pre-determination. I also started just reflexively doing 3D vs. IMRT planning comparisons on all cases.

All good points. I've had a similar experience. Just got a call from an RO MD reviewer for a p2p from anthem BCBS after the fact of treating a patient with imrt even though no auth was needed. Thankfully we did the comparison and I rattled off the necessary info over the phone.

 

[bluebubbles]

Supplemental income sounds like a zero-sum game. If you work part-time for insurance as a rad onc, it increases the amount of time other rad onc's in your community spend doing work without increasing their income. Go for it if you hate other rad onc's and want the pleasure of denying their IMRT plans.

 

[OTN]

OMG, don't get me started on this. Could go on and on about all the **** I've dealt with, particularly this year. The PPOs have gone insane in my area with their pre-auth games. We call the insurance to request pre-auth, are told we don't need it for the diagnosis code, then receive denials of payment for not having pre-auth. Of course, the insurance won't give us any feedback until end of treatment, so we don't even get a denial until several weeks after patient is done. We will call two different departments in the insurance company and one operator tells us pre-auth needed, the other says no need. We've even had them on 3 way calls giving us conflicting information. UM dept says no pre-auth, but claims dept on same call says it's needed. I stopped listening to the operators and UM dept and go directly to the websites. If the website says preauth required for IMRT, I refuse to treat patient until I have one. I make patient call as well. If I verify no preauth needed on website I still ask for a pre-determination. I also started just reflexively doing 3D vs. IMRT planning comparisons on all cases.

I never start an IMRT case without prior auth, no matter what the payer says.

 

[medgator]

I never start an IMRT case without prior auth, no matter what the payer says.

Even with Medicare?

 

[OTN]

Even with Medicare?

Good point we’re more lenient with Medicare patients.

 

[deleted18755]

I have definitely spoken to practicing ROs for p2p calls for igrt/imrt approvals (not through evicore, but other prior authorization companies), and I suspect they do the work for the exact reason you mention.... Supplemental income

Does anybody know how the reviewer is actually paid? It usually feels like they get paid more for a denial then an approval (but maybe that's just what it feels like to me since they are giving me a hard time) while every now and then I swear the guy couldn't care less and is ready to approve anything as if he gets paid the same either way (I can hear the guy watching a video or tv in the background and have definitely heard them chewing or dishes/silverware making noise and once literally heard a kid scream "mommy" in the background). It seems like they can take the call from wherever they want and at least every now and then the reviewer couldn't care less and is sneaking in a little extra cash while half listening to me while eating lunch or watching espn!.

8-10 years ago or so the reviewer was always obviously just some retired guy with a medical license who was flipping through guidelines but didn't know a thing about radiation oncology but for the past few years at least it's always been a radiation oncologist, and one who at least sounded young or younger.

Awhile ago a family friend said he signed up to be a reviewer just to get back at the insurance company with the intent of approving everything until he got fired (which happened after not too long but he couldn't care less, especially since he was paid by the hour or case). I thought he was joking but honestly not sure.

 

[medgator]

Awhile ago a family friend said he signed up to be a reviewer just to get back at the insurance company with the intent of approving everything until he got fired (which happened after not too long but he couldn't care less, especially since he was paid by the hour or case). I thought he was joking but honestly not sure.

Sounds like a good idea. Hmmmmm.

That being said, I'll probably put the kabosh on 20 fx or unnecessary imrt for mets etc

 

[Mandelin Rain]

Does anybody know how the reviewer is actually paid? It usually feels like they get paid more for a denial then an approval (but maybe that's just what it feels like to me since they are giving me a hard time) while every now and then I swear the guy couldn't care less and is ready to approve anything as if he gets paid the same either way (I can hear the guy watching a video or tv in the background and have definitely heard them chewing or dishes/silverware making noise and once literally heard a kid scream "mommy" in the background). It seems like they can take the call from wherever they want and at least every now and then the reviewer couldn't care less and is sneaking in a little extra cash while half listening to me while eating lunch or watching espn!.

8-10 years ago or so the reviewer was always obviously just some retired guy with a medical license who was flipping through guidelines but didn't know a thing about radiation oncology but for the past few years at least it's always been a radiation oncologist, and one who at least sounded young or younger.

Awhile ago a family friend said he signed up to be a reviewer just to get back at the insurance company with the intent of approving everything until he got fired (which happened after not too long but he couldn't care less, especially since he was paid by the hour or case). I thought he was joking but honestly not sure.

I got tagged to a job offering 250k for part time supplemental income for rad oncs. I suspected it was Evicore (it was), but I inquired. Once I found out what it was, I disengaged immediately without further info. Not sure if there is a quota for denials or what benchmarks you need to hit to remain employed, but the cited pay seemed WAYYYY too good to be true. .

 

[Neuronix]

I got tagged to a job offering 250k for part time supplemental income for rad oncs.

When I graduated I had offers at this level or even lower. I mean 250k-300k was the going rate for full-time clinical, and some places had base incomes even less than that, which you were supposed to make up on bonus. Meanwhile, you can work part-time and make 250k denying care with insurance now? Our specialty has gone completely insane.

I personally would never do it except to do what was proposed--approve everything until fired. I would never work to actively stop treatment from being given. Some of the conversations I've had on the phone with some of these ***hole reviewers have been completely insane. Just looking for an arbitrary reason to deny. It's a sad thing that those people can even sleep at night.

I will temper my response a little by writing--I know people who were locked into working insurance reviews by a bad job market or non-compete. I also know someone I like who works for Evilcore. So I can understand why it happens. Still, it's an ugly part of our specialty in how prevalent this is becoming and how well it pays compared to actually being a physician and providing patients care.

 

[scarbrtj]

I got tagged to a job offering 250k for part time supplemental income for rad oncs. I suspected it was Evicore (it was), but I inquired. Once I found out what it was, I disengaged immediately without further info. Not sure if there is a quota for denials or what benchmarks you need to hit to remain employed, but the cited pay seemed WAYYYY too good to be true. .

I have some friends who've worked Evicore.
1) The 250k is for 40 hrs/week.
2) The minimum you can work is 20 hrs/week,and usually at least one full 8 hr day a week. So even with part-time work you can't maintain full time clinical practice. When you're "on," you're on... taking calls etc. No way you could have a little side patient problem and handle that and get back to the Evicore calls.
3) There's no quota, but they don't like constant approving of stuff; if you do that, you do not stay employed by them for long
4) There are guidelines behind the guidelines. Kind of like the secret Starbucks menu. So if you know the secret password or whatever, you can get more approvals. Here's a little nugget 'o info and I hope Evicore is not reading this. In their guidelines, they give you holy hell for IMRT for rectal e.g. But if you say "I'm using a belly board," they will approve IMRT every time. The "secret" guidelines. These can change, however, based on whatever prevailing whim the rad oncs in the Evicore "practice" are into at the moment.
5) You do work from home with Evicore and theoretically can do it from anywhere as long as there's a good Internet connection,.

 

[medgator]

4) There are guidelines behind the guidelines. Kind of like the secret Starbucks menu. So if you know the secret password or whatever, you can get more approvals. Here's a little nugget 'o info and I hope Evicore is not reading this. In their guidelines, they give you holy hell for IMRT for rectal e.g. But if you say "I'm using a belly board," they will approve IMRT every time. The "secret" guidelines. These can change, however, based on whatever prevailing whim the rad oncs in the Evicore "practice" are into at the moment.

Can get IGRT approvals in 3D/palliative cases if the pt's BMI is >30/obese, since skin marks are unreliable in those situations (at least for some payors guidelines, dispensed by Evicore)

 

[evilbooyaa]

The previous 2 posts are what I want to hear more of - little tricks to justify certain things to insurance companies. I'm surprised on the rectal thing - I figured a belly board would be a contraindication to IMRT not an approval.

But yes, ASTRO fighting prior auth is a welcome thing IMO.

 

[Neuronix]

The previous 2 posts are what I want to hear more of - little tricks to justify certain things to insurance companies. I'm surprised on the rectal thing - I figured a belly board would be a contraindication to IMRT not an approval.

But yes, ASTRO fighting prior auth is a welcome thing IMO.

It is totally moving target. They change their guidelines constantly and your response can vary from reviewer to reviewer. If they read this thread they're liable to mutate the guidelines again.

 

[medgator]

It is totally moving target. They change their guidelines constantly and your response can vary from reviewer to reviewer. If they read this thread they're liable to mutate the guidelines again.

This is all going to eventually end with bundled patients

 

[seper]

250K is a very good salary IMO. One of my former colleagues (she is in her early 50's) quit our hospital and is doing reviews full time.

 

[SneakyBooger]

Our group keeps a database of the rad oncs we get calls from. No one seems to view approvingly the rad oncs doing this service for insurance companies. We review the list each week after chart rounds.

Must be a lot of money in it as they do their job with plenty of apetite.

 

[medgator]

Our group keeps a database of the rad oncs we get calls from. No one seems to view approvingly the rad oncs doing this service for insurance companies. We review the list each week after chart rounds.

Must be a lot of money in it as they do their job with plenty of apetite.

Given that there isn't as much money/jobs in the "solution" of providing rad onc service in the current environment, folks have figured out there is money to made in the "problem" of prior auth

 

[Mandelin Rain]

250k to sell your soul over the phone? Sign me up!

What's a soul worth these days, anyway?

 

[xrthopeful]

Actually a good idea to publically list the names of all these guys and gals

 

[medgator]

Actually a good idea to publically list the names of all these guys and gals

I'm game if mods bless

 

[thecarbonionangle]

250k to sell your soul over the phone? Sign me up!

What's a soul worth these days, anyway?

residency programs can apparently be sold. Cost of a warm body? Hard to say but not so much? Cost of a soul? Depends on the source of the warm body, i’d wager

 

[xrthopeful]

most of the rad oncs ive spoken to are at least more with the program and reasonable than before when it used to be retired FM docs who had no idea about cancer. but still. being easier to talk to doesn't make it right.

 

[medgator]

most of the rad oncs ive spoken to are at least more with the program and reasonable than before

You mean when they are fine with you choosing wisely for 3-4 weeks of breast xrt but make you submit a 3D/imrt plan comparison for a stage IIIA lung pt?

Nope

 

[evilbooyaa]

I'm game if mods bless

Eh. These are not public figures posting on social media. I do not think this is OK to 'name and shame' those who work for insurance companies.

I've seen some folks do dumb stuff that SHOULD get rejected (2Gy x 10 IMRT to a myeloma met that has never received RT anywhere near the area, as one example), IMO.

 

[xrthopeful]

Eh. These are not public figures posting on social media. I do not think this is OK to 'name and shame' those who work for insurance companies.

I've seen some folks do dumb stuff that SHOULD get rejected (2Gy x 10 IMRT to a myeloma met that has never received RT anywhere near the area, as one example), IMO.

right.

It's hard to balance the need for some sort of oversight with the burdens of pre-auth for ridiculous SOC stuff.

but I agree, some people would go buck wild if given free rein.

 

[Neuronix]

Just a note that I'm not effectively moderating since I'm covering the main center all day today on Christmas Eve. I've got a young mother with severe bone metastasis pain and epidural extension who we're worried about pending cord compression on. We did an 8 Gy x 1 fraction plan 3D conformal overnight, using 3D-CRT since this is abutting a prior treatment field (could have justified fractionated IMRT...), special physics consult for composite plan with EQD2 calcs which worked out ok. We threw that together quickly this morning and plan ready for lunchtime treatment today.

EXCEPT, peer review from Evilcore not available until 2:30 PM. Then they tried to call my cell, and despite me getting calls to my cell all day from various places, it went to voicemail. Now I have to wait until 4:15 PM on Christmas Eve just to get an urgent single fraction palliative bone met case approved. **** YOU EVILCORE.

 

[Mandelin Rain]

Just give it. If they don’t pay, charge it to the game.

 

[scarbrtj]

Just a note that I'm not effectively moderating since I'm covering the main center all day today on Christmas Eve. I've got a young mother with severe bone metastasis pain and epidural extension who we're worried about pending cord compression on. We did an 8 Gy x 1 fraction plan 3D conformal overnight, using 3D-CRT since this is abutting a prior treatment field (could have justified fractionated IMRT...), special physics consult for composite plan with EQD2 calcs which worked out ok. We threw that together quickly this morning and plan ready for lunchtime treatment today.

EXCEPT, peer review from Evilcore not available until 2:30 PM. Then they tried to call my cell, and despite me getting calls to my cell all day from various places, it went to voicemail. Now I have to wait until 4:15 PM on Christmas Eve just to get an urgent single fraction palliative bone met case approved. **** YOU EVILCORE.

Just give it. If they don’t pay, charge it to the game.

The worst part of this, and correct me if I'm wrong Neuronix, is to be in a department where the doctor does not have final say on treat or no treat regardless of insurance issues. Clearly the only reason Neuronix hasn't treated by lunchtime is due to internal departmental pushback of some sort; I face it, others face it, it's crazy and IMHO as crazy as the Evicore issue but in reverse. Only in rad onc; lots of "I Know Better" coders and billers etc. Neuronix, go ahead and treat... Evicore has a national no-prior-auth-necessary for emergencies. OF COURSE, you will have to get your billers/coders/admins to believe you. Wishing you Merry Xmas and freedom from moral injury.

EVICORE GUIDELINES
What is the most effective way to get authorization for urgent requests?
The most efficient way to obtain preauthorization for urgent requests is via web portal, as an immediate approval can be obtained. You may also contact eviCore healthcare by phone at 1-866- 686-4452, indicating the request is urgent. For outpatient radiation therapy in urgent situations only, treatment may be started without prior authorization; however the treatment must meet urgent/emergent guidelines. eviCore will make a decision and notify the patient and provider as expeditiously as the enrollee’s health condition might require, but no later than 72 hours after receiving the enrollee’s request.

 

[throwaway.radonc]

playing devils advocate, what about all those practices that are overbilling? I know a group that would always start with IMRT for breast and wait until not approved. How do we ask for no prior auth when this is happening?

 

[Neuronix]

Thanks scarb I had no idea. We had finished early given the holiday and waited hours for that auth to come through. Probably lost more money keeping the staff around.

 

[BobbyHeenan]

In 5+ years I really haven’t had any denials I thought we’re completely unreasonable until this last week.

stage 4 NSCLC alive now 5 years (!!!) after initial diagnosis where she had only alung tumor and 2 small brain mets. S/p SRS to both and chemo and I/O.

now with solitary “oligoprogression” in an adrenal met. Evicore (via United) denying SBRT. Will approve 10 fraction 3D. Ugh. I “lost” my first peer to peer bc they said United expressly prohibits SBRT for adrenal oligoprogression.

I’m starting the “second appeal” process.

if all else fails I *think* I can do a 4D ct sim with CBCT directed 8-10 field 3D plan at like 50 in 10 and getpretty good dosimetry, but not ideal.

 

[BobbyHeenan]

Just give it. If they don’t pay, charge it to the game.

That’s what I do.

then I tell the billers if it doesnt go through don’t charge patient.

thankfully I have some good admins that agree if patient needs it wedo it. I don’t abuse that power but it’s nice to have it.

 

[Neuronix]

if all else fails I *think* I can do a 4D ct sim with CBCT directed 8-10 field 3D plan at like 50 in 10 and getpretty good dosimetry, but not ideal.

We've been doing 60 in 8 with 3D arcs when this happens.

 

[PhotonBomb]

We've been doing 60 in 8 with 3D arcs when this happens.

OMD

 

[scarbrtj]

playing devils advocate, what about all those practices that are overbilling? I know a group that would always start with IMRT for breast and wait until not approved. How do we ask for no prior auth when this is happening?

Overbilling is doing something and billing something else at a higher price. What you're referring to is actually overutilization, which is a different argument; e.g., can argue RT is over-utilized in breast cancer in general. The first randomized trial of IMRT for anything was in breast, and it proved its worth. It is strange twist of medical radiation history that it became so vilified (but, obviously, only in certain clinical settings). Blame ASTRO, somewhat, for determining rather all by its lonesome what IMRT is and isn't, weirdly and awkwardly in opposition to what had been mentioned/shown previously.

 

[Mandelin Rain]

I will say, it's been odd how much time and effort has been put forth by our leadership to ensure radiation oncologists are paid less money. Some of these crusades have proven beneficial to patients, but others have been on a purely semantic basis like that referenced above.

Meanwhile, some FP salaries have more than doubled in past decade (citation: guest post on WCI). I wonder if their leadership is looking for ways to stop this?

 

[sunnybunnyhunny]

In 5+ years I really haven’t had any denials I thought we’re completely unreasonable until this last week.

stage 4 NSCLC alive now 5 years (!!!) after initial diagnosis where she had only alung tumor and 2 small brain mets. S/p SRS to both and chemo and I/O.

now with solitary “oligoprogression” in an adrenal met. Evicore (via United) denying SBRT. Will approve 10 fraction 3D. Ugh. I “lost” my first peer to peer bc they said United expressly prohibits SBRT for adrenal oligoprogression.

I’m starting the “second appeal” process.

if all else fails I *think* I can do a 4D ct sim with CBCT directed 8-10 field 3D plan at like 50 in 10 and getpretty good dosimetry, but not ideal.

You can usually get a "5 fraction IMRT" approved if 3D would not meet constraints

Sent from my LM-V405 using Tapatalk

 

[BobbyHeenan]

You can usually get a "5 fraction IMRT" approved if 3D would not meet constraints

Sent from my LM-V405 using Tapatalk

Thanks, I’m looking into options.

Not sure I’m comfortable billing just 5 fraction IMRT (and not SBRT) for 40 or 50 in 5 adrenal case. I bill pro only fees and would also need to make sure hospital ok billing Imrt and not sbrt there.

* may be hypocritical of me though bc I don’t bill SBRT for 30/5 breast.

 

[qwerty89]

I will say, it's been odd how much time and effort has been put forth by our leadership to ensure radiation oncologists are paid less money. Some of these crusades have proven beneficial to patients, but others have been on a purely semantic basis like that referenced above.

Meanwhile, some FP salaries have more than doubled in past decade (citation: guest post on WCI). I wonder if their leadership is looking for ways to stop this?

Any link?