Prior authorization: biggest problem small radiation oncology practices are facing

Nov 4, 2018
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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

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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.
 
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medgator

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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
 
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Gfunk6

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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

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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

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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

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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.
 
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bluebubbles

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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.
 
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OTN

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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.
 
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oldking

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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.
 
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medgator

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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
 
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Mandelin Rain

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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. .
 
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Neuronix

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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

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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,.
 
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medgator

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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

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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.
 
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Neuronix

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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

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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
 
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seper

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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.