By Howard Sandler, MD, MS, FASTRO, and Constantine Mantz, MD, FASTRO
ASTRO members are frustrated by the scourge of restrictive and burdensome prior authorization requirements that frequently result in care delays or outright denials of coverage, and ASTRO is dedicating significant advocacy resources, across the Health Policy and Government Relations Councils, to this issue. In member surveys, radiation oncologists consistently rank prior authorization as the top challenge facing practices, and ASTRO has conducted and publicized numerous studies demonstrating the negative impact of prior authorization on patients and practices.
The Health Policy Council’s Payer Relations Committee (PRC) engages with Radiation Oncology Benefit Managers (ROBM) and payers to educate them on appropriate coverage and directly advocate on behalf of members that are experiencing delays or denials for standards of care that are reasonable and appropriate. In addition to regular communications with ROBMs and payers, ASTRO issues Model Policies for each radiation therapy modality of treatment that are designed to educate payers on appropriate coverage based on clinical evidence. ASTRO also provides ROBMs and payers with a copy of the ASTRO Radiation Oncology Coding Resource and access to webinars that detail appropriate coverage policies. Despite these efforts, ASTRO members continue to face restrictive coverage policies, some of which are described below.
eviCore, a ROBM that contracts with many payers, has determined that conventional fractionation schemes for breast and prostate cancer are no longer medically necessary. They will only approve hypofractionation, which is a shorter course of treatment, for these two disease sites. This restrictive policy ignores the fact that some patients have certain clinical characteristics that are more suitable for longer course treatments. ASTRO has pushed back on this policy, as it is merely designed to save money. Additionally, it does not take into consideration the clinical characteristics of the patient, nor does it recognize the important role of shared decision making between a doctor and their patient. Despite our efforts, eviCore refuses to reconsider this policy.
Another issue ASTRO frequently hears about is complaints regarding eviCore’s peer-to-peer reviews. These coverage determination reviews have increased dramatically during the COVID-19 PHE, consuming significant amounts of physician time and causing a high level of frustration. ASTRO members frequently report that peer reviews often involve a physician that is not a radiation oncologist, resulting in inappropriate denials and delayed care. In order to help address the issue, ASTRO has devoted a section of its website to house sample ROBM appeal form letters that radiation oncology practices have successfully used to appeal denials. This allows practices across the radiation oncology community to share letters with other radiation oncologists to help save time and administrative burden associated with growing denials and delays in care.
Private payers are also utilizing prior authorization as part of their coverage review process. ASTRO has written numerous letters to payers about inappropriate prior authorization denials and restrictive medical policies. ASTRO sent a comment letter to eviCore on their oligometastases policy, after several members reported receiving denials that did not align with current guidelines.
UnitedHealthcare (UHC) recently announced the establishment of a prior authorization electronic portal for approval of all the following services: IMRT, PBT, SBRT and IGRT; “Special and Associated radiation therapy services;” and fractionated breast, prostate and lung cancers, and bone metastasis. This list encompasses a significant portion of the services delivered by radiation oncologists. ASTRO’s Payer Relations Committee, Health Policy Committee and Clinical Affairs and Quality Council met with UHC to emphasize the negative impact this policy would have on radiation oncologists and their patients. UHC made modest modifications; however, members still report delays in patient care and other administrative burdens despite the electronic format.
ASTRO supports professionally developed and vetted clinical practice guidelines, appropriateness of care criteria, and consensus-based model policies developed in a transparent manner with peer review and input as a foundation for clinical decision making. We oppose restrictive practice guidelines that oversimplify the process of individual patient management and abrogate the professional judgments that are often only possible within the private boundaries of a direct patient-doctor relationship.
With prior authorization out of control, one of ASTRO’s top advocacy priorities is to push Congress and Medicare to intervene. ASTRO has sent numerous letters to the Centers for Medicare and Medicaid Services describing how restrictive prior authorization practices are keeping patients from the care they need and the care they have paid for in premiums. Congress is getting closer to passing ASTRO-backed legislation to enact significant prior authorization reforms. Passage of the Improving Seniors Timely Access to Care Act may possibly occur later this year, as now more than 330 representatives and senators have cosponsored the bill. The bill was a priority focus during ASTRO Advocacy Day, as radiation oncologists pressed their members of Congress during more than 100 meetings in May to advance the legislation.
ASTRO is committed to reining in excessive prior authorization, and we encourage members to voice their concerns directly to members of Congress via ASTRO’s grassroots system and social media. If you are experiencing difficulties with eviCore or payers, please contact Emilio Beatley, ASTRO Health Policy Analyst, so we can provide resources and engage on your behalf.