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October 9, 2023

Ensuring Reimbursement Success: 6 Prior Authorization Tips for Oncology Providers

by Susan Lawson-Dawson | Healthcare Technology, Prior Authorization

In the ever-evolving realm of healthcare, oncology stands out as a field that requires prompt, precise, and above all, compassionate care. Every procedure, medication, or therapeutic session can be pivotal in a patient’s battle against cancer. And herein lies the challenge: How do you ensure that potentially life-altering treatments earn prompt approval, reducing gaps in patients’ care journeys and in your revenue cycle simultaneously? 

Addressing process inefficiencies with prior authorization automation makes a huge difference. After all, prior authorization doesn’t just result in an approval or denial for patient care. It also confirms a payer’s commitment to reimburse you for delivering a particular medical service or medication. But as vital as it is, manual prior authorization embodies complexity, particularly with complex cancer care regimes. The following tips can help you better navigate the labyrinth of prior authorizations, ensuring reimbursement success.

1. Two Distinct Facets: Medical & Pharmacy Benefits

There are two primary paths through which oncology treatments are authorized: medical benefits (infusions, surgeries, radiology, etc.) and pharmacy benefits (oral medications, certain injectables, etc.). Understanding which treatment aligns with which benefit type is crucial for a streamlined PA process. Submitting the right authorization request to the appropriate department minimizes delays. The challenge is determining which is needed quickly. That’s where the next tip comes in.   

2. Embrace Intelligent Automation

Traditional prior authorization processes have long been hindered by labor-intensive manual data entry and antiquated paper-based systems, leading to cumbersome and often protracted workflows. These outdated methods not only delay essential healthcare services but also increase the likelihood of errors that lead to delays, denials, and declining reimbursements. However, thanks to the wave of digital transformation sweeping across healthcare, organizations can benefit from intelligent automation of prior authorizations, fostering seamless data exchange between previously isolated realms of patient, provider, and payer information. 

3. Stay Updated on Treatment Protocols

Oncology is an ever-evolving field. New medications, treatments, and research findings emerge frequently. And prior authorization requirements shift nearly as much, particularly when it comes to innovative therapies. “For decades, medical cancer treatment has generally meant chemotherapy, radiation, or surgery, alone or in combination. But things are changing rapidly. Today, new approaches such as immunotherapies and targeted therapies are becoming available, with many more in research and development,” notes a Duke University School of Medicine article. Staying updated ensures that you maintain alignment with the latest protocols, which can be pivotal during the prior authorization process.

4. Train the Team

A well-trained team often stands as the dividing line between fast prior authorizations and exasperating hold-ups. Engaging your staff in periodic workshops can dramatically enhance the accuracy of submissions. Moreover, by routinely organizing information sessions on emerging pharmaceuticals, teams can stay informed about the latest advancements, ensuring they’re well-equipped to handle diverse patient needs. By fostering a culture of ongoing knowledge sharing and training, you empower your team to manage prior authorizations with confidence, precision, and efficiency.

5. Monitor and Learn from Denials

While your goal is to minimize prior authorization denials, the fact remains that denials still happen. Instead of seeing denials as setbacks, look at them as opportunities for prior auth triage. Investigating the underlying reasons for each denial can help you determine how to refine your prior authorization process to prevent them in the future. Afterwards, initiate targeted training sessions and share these findings across teams. This keeps everyone involved on the same page when you recalibrate and enhance existing processes. A systematic approach stands a better chance of significantly slashing future denial rates. 

6. Prioritize Patient Advocacy

Behind every prior authorization request is a cancer patient awaiting critical care. Prioritizing their needs, implementing a fast, transparent prior authorization process, and identifying patient financial assistance programs can make a world of difference to the patients you serve.

The intricacies of prior authorization in oncology can be daunting, especially if you still rely on an inefficient, error-prone manual process. With the right tools, strategies, and mindset, you can navigate this process seamlessly. Myndshft, the only unified prior authorization platform in the industry, makes short work of prior authorizations under medical or pharmacy benefits so you can focus on patients, not paperwork. What’s more, through a partnership with Atlas Health, you can embed patient financial assistance identification into your workflow too, creating an even more powerful patient-centric process. Equip your oncology practice to offer not just medical excellence, but also administrative efficiency, leading the way in holistic patient care.

Ready to get started?  Connect with Myndshft to learn more.