Health Services Research

PV QA 3 - Poster Viewing Q&A 3

TU_38_2974 - Impact of Insurance Preauthorization Requirements on Delays in Administering Proton Beam Therapy

Tuesday, October 23
1:00 PM - 2:30 PM
Location: Innovation Hub, Exhibit Hall 3

Impact of Insurance Preauthorization Requirements on Delays in Administering Proton Beam Therapy
A. Gupta1, R. Millevoi1, N. El Sebai1, S. Goyal2, A. J. Khan3, S. K. Jabbour1, N. J. Yue1, B. G. Haffty Jr1, and R. R. Parikh1; 1Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, 2George Washington University, Department of Radiation Oncology, Washington, DC, 3Memorial Sloan Kettering Cancer Center, New York, NY

Purpose/Objective(s): Insurance preauthorization (PA) regarding proton beam therapy (PBT) varies widely and may not completely align with clinical practice guidelines, yet there has been no objective assessment of PA policies on delivery of PBT. We sought to evaluate the impact of PA requirements on utilization and delays in administration of PBT.

Materials/Methods: A retrospective chart review was performed on all patients evaluated for PBT at our institution between April 2015 and December 2017. Data on patient age, treatment site, diagnosis, history of irradiation, clinical trial enrollment, insurance category, PA requirement, and dates of simulation, PA determination, and radiation start were collected and analyzed. Days from simulation to PA determination and treatment start were tabulated and compared for differences using two-sample t-tests and analysis of variance.

Results: A total of 407 patients were evaluated for PBT, of whom 276 (68%) received PBT, including 238 adults (representing 65% of all adults evaluated) and 38 pediatric patients (representing 95% of all pediatric patients evaluated). The remaining patients were treated with photons or did not undergo treatment at our institution. Of patients undergoing PBT, 64 (23%) were re-irradiation cases and 18 (7%) were enrolled on a phase 3 randomized clinical trial. Preauthorization was required in 57% of cases. For adults requiring PA, 67 (36%) were initially approved, 58 (31%) were approved after appeal, and 60 (32%) were denied, including nine re-irradiation cases; mean number of days to start treatment were 24.8, 32.3, and 28.7 days, respectively. For pediatric patients requiring PA, 26 (90%) were approved, 3 (10%) were approved after appeal, and 0 were denied; mean number of days to start treatment were 19.3 and 18.7 days, respectively. PA requirement was associated with a significant delay in starting PBT for adults (28.7 vs. 20.9 days, p<0.01), while for pediatric patients there was no significant difference (19.7 vs. 21.5 days, p=0.34). Commercial insurers accounted for the majority of PBT denials (88%) with large differences between individual insurers. All but one (99%) of Medicare patients and 89% of Medicaid patients were covered for PBT. Commercially-insured adults demonstrated significant delays in starting treatment (27.2 days) compared to Medicare-insured adults (20.6 days) (p<0.01) and Medicaid-insured adults (23.6 days) (p=0.04).

Conclusion: This represents the first comprehensive assessment of insurance preauthorization on clinical utilization and delays associated with PBT. Preauthorization requirements in their current state represent a significant burden in initiating PBT, through extensive time and resources associated with approval and subsequent delays in patient care. Payors and providers should seek to align appropriateness regarding optimal PBT use to ensure timely, efficient, and safe patient care.

Author Disclosure: A. Gupta: None. R. Millevoi: None. S. Goyal: Employee; Princeton Medical Group. Independent Contractor; Isoray Medical, Hines Associates. Research Grant; American Lung Association. Consultant; Hines Associates. Travel Expenses; American Lung Association. Senior Editor; Advances in Radiation Oncology. Division Chief; George Washington University. A.J. Khan: Research Grant; Elekta, Cianna Medical. Consultant; Elekta. S.K. Jabbour: Research Grant; Merck. N.J. Yue: Chairman of Board; Sino-American Network for Thera. Radiology an Onc. Board of Directors; CAMPEP. B.G. Haffty: Research Grant; Breast Cancer Research Foundation. Board of Directors-Science Liaison; RSNA.

Apar Gupta, MD, MBA

No relationships to disclose.

I completed a combined seven-year BA/MD program at Boston University and received a MBA during medical school. I'm currently a PGY-4 resident at Rutgers Cancer Institute of New Jersey with research interests in breast hypofractionation and value-based medicine. I currently serve on the ASTRO Payer Relations Committee and I'm actively investigating the burden of prior authorization on radiation oncology practices.


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TU_38_2974 - Impact of Insurance Preauthorization Requirements on Delays in Administering Proton Beam Therapy

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