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News Latest News FDA News Adverse Event Management Supportive Care Disparities in Cancer Care Drug Safety Radiation Oncology Survivorship Practice Management Prevention Contributors Media Expert Connections Podcasts Videos Conferences Conference Coverage Conference Listing Publications CME/CE Continuing Education Resources Case-Based Digest Oncology Drug Crash Course Webinars Cancer Summary Slides MPN Symptom Management Subscribe Print Subscription eNewsletter Partners Specialty Advanced Practice Providers Clinical Breast CancerGastrointestinal CancerGenitourinary CancerGynecologic CancerHematologyImmunotherapyLung CancerMyeloproliferative NeoplasmsNurse NavigationPreventionSupportive Care Quality Improvement News Latest News FDA News Adverse Event Management Supportive Care Disparities in Cancer Care Drug Safety Radiation Oncology Survivorship Practice Management Prevention Contributors Media Expert Connections Podcasts Videos Conferences Conference Coverage Conference Listing Publications CME/CE Continuing Education Resources Case-Based Digest Oncology Drug Crash Course Webinars Cancer Summary Slides MPN Symptom Management Subscribe Print Subscription eNewsletter Partners Advertisement Breast Cancer | Lung Cancer | Gynecologic Cancers | Hematology | Skin Cancer | Supportive Care | Adverse Event Management | Brain Cancer | Disparities in Cancer Care | Drug Safety | Gastrointestinal Cancer | Genetics | Genitourinary Cancer | Head and Neck Cancers | Immuno-Oncology | Myeloproliferative Neoplasms | Nurse Navigation | Pediatric Cancer | Practice Management | Prevention | Radiation Oncology | Sarcomas | Survivorship View All >> * Adverse Event Management * Brain Cancer * Breast Cancer * Disparities in Cancer Care * Drug Safety * Gastrointestinal Cancer * Genetics * Genitourinary Cancer * Gynecologic Cancers * Head and Neck Cancers * Hematology * Immuno-Oncology * Lung Cancer * Myeloproliferative Neoplasms * Nurse Navigation * Pediatric Cancer * Practice Management * Prevention * Radiation Oncology * Sarcomas * Skin Cancer * Supportive Care * Survivorship PRIOR AUTHORIZATION IS TOP ADMINISTRATIVE CHALLENGE OF 2023 February 16, 2023 Feature Article Oncology Nursing NewsFebruary 2023 Volume 17 Issue 1 Prior authorization costs clinicians time and money. Heading into 2023, prior authorization was listed as a top administrative challenge. Prior Authorization Is Top Administrative Challenge of 2023 The number of prior authorization requests continues to increase despite promises to the contrary by payers. The increase is costing physicians time and money. In a Medical Group Management Association (MGMA) poll, 70% of medical groups queried indicated that prior authorizations had increased in the past year. Physicians say their practices continue to struggle with either a lack of response or no response from payers, increased time spent by staff to try to gain approval, and a lack of automation in the process. These difficulties can lead to delays in patient care. A University of Colorado study found that 93% of physicians reported care delays and that 82% reported cases of treatment abandonment (when the patient does not follow through) because of prior authorization requirements. “There’s not 1 standardized way to submit prior authorizations or additional information— maybe clinical information or chart information—to the health plans,” Anders M. Gilberg, MGA, senior vice president of government affairs for MGMA, said. “Each health plan thinks they have the best proprietary way to make it really easy.” But for practices with 20 to 30 payers, that can mean 20 to 30 different websites and passwords. “The way it works is you have to hire staff to go in there and learn each of those processes, which is time consuming and redundant,” Gilberg said. “Ideally, we’re looking for 1 standard and 1 way of submitting them, such as pushing a button or maybe having it integrated with an electronic medical record and the clinical record. We could provide the information health plans need but [we want to] do so in a streamlined way….” Although that solution doesn’t exist yet and physicians can’t change the prior authorization demands from payers, they can take the following steps to minimize the burden. Designate a prior authorization champion. Having 1 staff member run point on prior authorizations will help that individual learn what each payer wants and the best ways to get authorizations approved in a timely manner. Keep detailed notes for each patient. All it takes is 1 piece of information to be missing from a patient’s chart for a payer to deny the authorization. Always keep this in mind when documenting a patient’s condition and what tests have been done. If something is abnormal, document it. Learn what payers want. Payers will have different requirements before authorizing tests such as an MRI. If the payer requires an x-ray first, make a note of that for future reference and complete as many of the requirements as possible before submitting the prior authorization. Be persistent. Just because a payer denies the first request doesn’t mean you should give up. Some payers have staff with minimal medical backgrounds who review initial requests and may just be looking for key trigger words as a reason to reject a claim. An appeal will most likely go to someone with more medical training. Recruit the patient. Have the patient call the insurance company if necessary. They will be talking to a different department and may either get a different answer or gain clues as to what is needed to get the prior authorization approved. Escalate, escalate, escalate. There is little point in arguing with a payer-employed nurse over a complex medical issue that may be well outside their expertise. Ask for a peer-to-peer review or, in extreme cases, to speak with the medical director or chief medical officer. They still may not have experience in the relevant specialty but will at least have a background to better understand the specific challenge being addressed. Download Issue PDF Articles in this issue -------------------------------------------------------------------------------- A Plea to Let Patients With Cancer “Just Eat” Prior Authorization Is Top Administrative Challenge of 2023 Nursing Education Can Be a Lifelong Marathon. Are You Ready for the Race? 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Related Content Advertisement -------------------------------------------------------------------------------- Perioperative Tislelizumab Plus Chemo Improves Event-Free Survival in Resectable NSCLC March 1st 2024 Article Treatment with neoadjuvant tislelizumab plus platinum-based doublet chemotherapy, followed by surgery and adjuvant tislelizumab, improved event-free survival in patients with resectable non–small cell lung cancer. -------------------------------------------------------------------------------- What New Cancer Drugs Were Approved in 2023? January 1st 2024 Podcast In this special episode of The Vitals, we ring in the New Year 2024 by combing through 2023 FDA approvals. -------------------------------------------------------------------------------- Immune Engager Therapies Improve Responses, PFS in RRMM After CAR T-Cell Therapy February 29th 2024 Article Immune engager therapies, according to a retrospective study of real-world patients, had the best rates of responses and progression-free survival in patients with multiple myeloma whose disease relapsed after treatment with idecabtagene vicleucel. -------------------------------------------------------------------------------- Finley-Oliver Talks Talquetamab and Other Later Line Multiple Myeloma Therapies December 14th 2023 Podcast Beth Finley-Oliver, MSN, ARNP, AGNP-BC, recaps part of her presentation from the 2023 JADPRO meeting about caring for patients with high-risk multiple myeloma. -------------------------------------------------------------------------------- Long-Term Survivors of Childhood Cancer at Higher Risk of Death Following Heart Issues; Threshold for Treating Risk Factors Should Be Lower February 28th 2024 Article New research out of VCU Massey Comprehensive Cancer Center and VCU Health Pauley Heart Center indicates that survivors of childhood cancer are at a significantly higher risk of death following a major cardiovascular event — including heart failure, heart attack or stroke — than the general public. -------------------------------------------------------------------------------- Mindfulness as Self-Care in Oncology Nursing May Also Improve Patient Care February 28th 2024 Article An expert discussed how the benefits of mindfulness in patients with cancer can also be applied to oncology nurses. 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