Background
Prior authorization (PA) is a determination of the necessity of an ordered test/procedure by a health insurer. Following a denial, a peer to peer (P2P) discussion can be used to appeal and potentially reverse the decision. We implemented a standardized prior authorization workflow (SPAW) to decrease the proportion of initial denials and P2P discussions. The objective of this study was to measure the effectiveness of the SPAW.
Methods
This was a quasi-experimental pre-test and post-test evaluation of all ordered imaging studies for surgical oncology patients at a quaternary cancer center. Pre-test evaluation was from October 2021 to March 2022 and post-test, November 2022 to June 2023. All patients with outpatient imaging orders for surgical planning or surveillance for gastrointestinal, endocrine, or skin cancers were included. The SPAW was led by the institution’s PA team and included templated PA, proactive PA, and team member training.
Results
A total of 2,581 outpatient imaging orders were included. The most common order was CT chest/abdomen/pelvis and least common was MR pelvis. There were 957 orders placed pre-intervention and 1,624 post-intervention. The number of orders that required prior authorization was similar in both eras, with 420 (43.9%) pre-intervention and 699 (43.0%) post-intervention (P=0.821). Of the orders that required prior authorization, 56 (5.9%) were initially denied pre-intervention and 57 (3.5%) were initially denied post-intervention (P=0.010). All were appealed through P2P. There were 32/56(57.1%) pre-intervention versus 43/57(75.4%) post-intervention overturned following P2P (P=0.446). Overall, the final denial rate pre-intervention was 2.5% (24/957) compared to 0.8% (14/1,624, P=0.001) post-intervention.
Conclusion
After implementation of a standardized workflow, there was a significant reduction in the proportion of initial insurance denials resulting in a lower rate of P2P discussions, and overall insurance denials. This study demonstrates that the PA process can be improved; however, the burden of PA and P2P remains significant. In the post-intervention study, 98% of orders necessitating PA were approved, supporting continued efforts to reform or eliminate PA.

Thomas Gamblin

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