Patterns of Unnecessary Insurer Prior Authorization Denials in a Complex Surgical Oncology Practice. J Surg Res 2023 Aug;288:269-274
Date
04/11/2023Pubmed ID
37037166DOI
10.1016/j.jss.2023.03.013Scopus ID
2-s2.0-85151667989 (requires institutional sign-in at Scopus site) 1 CitationAbstract
INTRODUCTION: Insurance prior authorization (PA) is a determination of need, required by a health insurer for an ordered test/procedure. If the test/procedure is denied, a peer-to-peer (P2P) discussion between ordering provider and payer is used to appeal the decision. The objective of this study was to measure the number and patterns of unnecessary PA denials.
METHODS: This was a retrospective review at a quaternary cancer center from October 2021 to March 2022. Included were all patients with outpatient imaging orders for surgical planning or surveillance of gastrointestinal, endocrine, or skin cancer. Primary outcome was unnecessary initial denial (UID) defined as an order that required preauthorization, was initially denied by the insurer, and subsequently overturned by P2P.
RESULTS: Nine hundred fifty seven orders were placed and 419 required PA (44%). Of tests requiring authorization, 55/419 (13.1%) were denied. Variability in the likelihood of initial denial was seen across insurers, ranging from 0% to 57%. Following P2P, 32/55 were overturned (58.2% UID). The insurers most likely to have a UID were Aetna (100%), Anthem (77.8%), and Cigna (50.0%). UID was most common for gastrointestinal (58.9%) and endocrine (58.3%) cancers. Average P2P was 33.5 min (interquartile range 28-40).
CONCLUSIONS: The majority of imaging studies initially denied were overturned after P2P. If all UIDs were eliminated, this would represent 108 less P2P discussions with an estimated time-savings of 60.3 h annually within a high-volume surgical oncology practice. Combined personnel costs to the health systems and stress on patients with cancer due to image-associated PAs and P2P appear hard to justify.
Author List
Merrill JR, Flitcroft MA, Miller T, Beichner B, Clarke CN, Maduekwe UN, Wang TS, Dream S, Christians KK, Gamblin TC, Evans DB, Kothari ANAuthors
Kathleen K. Christians MD Professor in the Surgery department at Medical College of WisconsinCallisia N. Clarke MD Chief, Associate Professor in the Surgery department at Medical College of Wisconsin
Sophie Y. Dream MD Assistant Professor in the Surgery department at Medical College of Wisconsin
Douglas B. Evans MD Chair, Professor in the Surgery department at Medical College of Wisconsin
Thomas Clark Gamblin MD Professor in the Surgery department at Medical College of Wisconsin
Anai N. Kothari MD Assistant Professor in the Surgery department at Medical College of Wisconsin
Ugwuji N. Maduekwe MD Associate Dean, Associate Professor in the Surgery department at Medical College of Wisconsin
Jennifer R. Merrill APP Outpatient in the Surgery department at Medical College of Wisconsin
Tracy S. Wang MD, MPH Professor in the Surgery department at Medical College of Wisconsin
MESH terms used to index this publication - Major topics in bold
Costs and Cost AnalysisHumans
Insurance Carriers
Retrospective Studies
Surgical Oncology
