Inhouse authorization center to improve reimbursement for outpatient chemotherapy infusions.

Purpose: The use of an inhouse authorization center to improve reimbursement for outpatient chemotherapy infusions is described.

Summary: Investigation of current processes revealed deficiencies in the coordination of an insurance authorization process at Norris Cancer Hospital, as chemotherapy orders were not always reviewed for third-party payer authorization. Same-day chemotherapy treatment was often provided incident to a secondary oncology consultation, resulting in higher payer denials due to the absence of advanced authorization for treatment. The authorizations conducted by nonclinical hospital personnel were often incomplete and inconsistent with the policies and procedures established by third-party payers. Treatments for off-label indications were deemed experimental by the payers and required extensive documentation and review time by the payer in order to authorize treatment. These requirements were not consistently followed by the hospital facility, causing disruptions in the payment revenue cycle due to a high volume of claim disputes and, consequently, unpaid claims. A clinically staffed authorization department was created to obtain third-party payer authorizations and serve as a centralized clinical department within the hospital to interface with payers and manufacturer-sponsored patient assistance programs. Within the first year of the center's inception, over $500,000 in drug replacement was recovered through patient assistance programs and a total of $1.4 million was recovered within 2.5 years. The number of disputed claims was also reduced.

Conclusion: Implementation of a clinical authorization process and use of manufacturer-driven patient assistance programs led to a reduction of disputed claims from third-party commercial payers and substantial savings in chemotherapy charges from January 2008 through July 2010.