The American Cancer Society expects newly diagnosed cancer cases in 2023 to exceed 1.9 million—and that figure doesn’t even factor in skin cancers not subject to reporting. The good news: The cancer death rates have been on the decline. Between 1991 through 2020, the rate dropped by 33%, thanks in large part to early detection and treatment advances. What hasn’t declined is the volume of prior authorizations required. If anything, volume is higher than ever as payers try to control costs through utilization management. 

As a result, says Oncology Insights, 70% of oncologists report needing full-time staff to manage prior authorizations and benefits issues. That’s where prior authorization software helps. Before we dive into how it works, let’s look at why oncology departments and practices—and the patients they treat—need automated prior authorization. 

Prior authorizations prolong patients’ cancer care journeys

Facing a cancer diagnosis is hard enough. Pursuing prior authorizations makes it even harder. Dr. Debra Patt, a breast oncologist in Austin, Texas, recently joined an AMA podcast to talk about the challenges posed by prior authorizations. She noted, “We encounter prior authorizations when we write for imaging studies to evaluate the extent of cancer involvement in a person. We encounter prior authorization when we write for new therapies.”  

In fact, a survey of American Society of Clinical Oncology (ASCO) members found that prior authorizations have a negative impact on patients, including: 

• Treatment delays (96%) 
• Diagnostic imaging delays (94%)
• Denials for cancer therapy (87%), genetic testing (76%), supportive care (72%), or cancer screening (61%)
• Pushing patients into second-choice therapy (93%) 
• Increasing patients’ out-of-pocket costs (88%)
• Higher hospitalizations or emergency room visits (74%)
• Care abandonment  (64%)
• Cancer progression (80%) or death (36%)

In announcing the findings, ASCO board chair Lori J. Pierce, MD, FASTRO, FASCO, said, “The survey results confirm what ASCO members have been experiencing first-hand for years, which is that large numbers of patients face indefensible delays or denials of cancer care.”

Prior authorizations are much more than hoops to jump through; they are barriers that prevent optimal care for patients. Dr. Patt acknowledged during the AMA podcast that “Sometimes we lose patients because cancer is terrible and maybe we don’t have other things to offer—but when we do have the best treatments to offer and cannot get it to the patients we serve who pay for their insurance, it’s really frustrating and demoralizing as a physician.” And if the physician feels demoralized, imagine how the patient feels. 

Prior authorization delays put cancer patients in an untenable position 

Delays in accessing necessary treatments have been associated with worse outcomes, including disease progression, decreased survival rates, and reduced treatment efficacy. For example, an analysis of mortality due to cancer treatment delay published by BMJ revealed, “Even a four week delay of cancer treatment is associated with increased mortality across surgical, systemic treatment, and radiotherapy indications for seven cancers.” 

In addition, inefficient prior authorization processes can result in increased distress and reduced quality of life for cancer patients. An ASCO article on the topic reveals, “Patients themselves experience vivid distress because of the intense efforts needed to advocate for their best care.” The pursuit of prior authorizations leads to increased anxiety, frustration and negative emotional and psychological well-being. The article further notes that patients who are too sick or inexperienced with navigating insurance processes, “… leading to a chain of inequities, detrimental outcomes, and avoidable sorrow.” As one patient told the authors, “That’s the last thing that I need as I fight for every minute of my life.” 

Prior authorization also has financial repercussions for patients. They may have to pay for treatments or medications initially and then wait for reimbursement from the insurance company. The financial burden can be overwhelming, particularly for patients already facing the high costs associated with cancer care. Some patients may even be deterred from pursuing necessary treatments due to the potential financial strain.

Such findings collectively demonstrate the negative impact that prior authorization can have on cancer patients, including treatment delays, increased distress and financial burdens

Benefits of prior authorization software

End-to-end prior authorization automation delivers clear benefits for both oncology providers and the patients they care for. 

Provider benefits

Automated prior authorization software streamlines the entire process, reducing the time and effort required by providers. It eliminates the need for manual paperwork, phone calls, and faxes, allowing providers to submit authorization requests electronically and receive responses in a timely manner. 

Plus, it reduces errors common in repetitive, manual data entry and prechecks the submission to validate that all necessary information is included in the authorization request. This increases the chances of getting approvals and reduces the need to rework preventable denials. 

As a result, it lowers administrative expenses typical with manual handling of prior authorization paperwork and follow-up activities. The software frees time-challenged clinicians and office staff from the burden, allowing them to focus on more rewarding, patient-centric work. 

Patient benefits

Faster and more efficient prior authorization processes contribute to improved patient experiences. Automated software enables providers to initiate and complete authorization requests quickly, reducing wait times for patients. This efficiency can lead to smoother care transitions too, a critical aspect of complex cancer care. 

Prior authorization software also helps with communication hurdles. Real-time data exchange and status notifications increases transparency, keeping providers informed about the progress which helps patients manage their expectations. It reduces anxiety and uncertainty by providing clear communication channels.

When prior authorization is automated, patients can focus on their health and well-being without the added stress of navigating complex administrative processes. By reducing the administrative burden, patients can have a smoother care experience, allowing them to concentrate on their recovery and overall health outcomes.

And guess what? Payers benefit too, from data-driven auto-adjudication and clinical decision support that helps them make faster, consistent decisions that benefit their members. 

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