UnitedHealthcare, which started requiring prior authorization for all injectable chemotherapy in Florida last May, will expand that requirement nationally this summer.
While the move will likely irk oncology practices that rue the hassle of prior authorization, it will save some practices from the shock and disappointment of finding that the chemotherapy they have already provided is not going to be paid by the insurer.
In 2008, UnitedHealthcare became the first national insurer to tie coverage for chemotherapy drugs used in outpatient settings to compliance with the guidelines published in the National Comprehensive Cancer Network (NCCN) Drugs and Biologics Compendium.
"Unfortunately, we still end up denying between $50 million and $60 million worth of chemotherapy every year because it didn't match NCCN criteria," said Lee Newcomer, MD, Senior Vice President for Oncology, Genetics and Women's Health at UnitedHealthcare. "And that means the physician has treated someone and they're holding the bag now for that expense."
Denials account for about five percent of the chemotherapy provided to outpatients covered by UnitedHealthcare.
The new online prior authorization process requires an oncology practice to submit clinical information about a patient that allows acceptable treatment regimens to be identified. "We're using the same NCCN rules that we've always used, but this process automates the selection of the regimen and makes it easier for physicians to know that they're going to get coverage," Newcomer said. "The physician won't have to guess whether or not the regimen is NCCN-compliant."
By collecting the patient information, the insurer is building a database that may shed light on the relative effectiveness of chemotherapy treatments.
"We will be putting 20,000 patients a year on prior-authorization protocols, where we will be collecting data about their specific clinical situation and the exact regimen that they're being treated with," he said. "I think that tool will allow us to start comparing drug regimens much more quickly than the episodes program."
He was referring to a three-year pilot in which five oncology practices were paid on an episode-of-care basis for the care delivered to patients with certain types of cancer. The program, which has been extended for additional years and expanded to include another practice, did prove that the pay approach dramatically decreased the total costs of cancer care (Journal of Oncology Practice doi: 10.1200/JOP.2014.001488), although the number of patients treated during the pilot was insufficient to draw conclusions about which treatments worked best.