Tackling Payor Issues

By Aaron Brammer

This blog post is modified from an article that appeared in Radiation Oncology News for Administrators Vol 33 No 2.  

In 2023, SROA and the American Society for Radiation Oncol­ogy (ASTRO) have teamed up to tackle payor challenges. Both societies are collecting examples of inappropriate denials and delays in care and identifying trends and themes. We will be meeting with the payors to present patient cases and scenarios of commonly experienced, inappropriate prior-authorization trends.

The goal of this SROA-ASTRO partnership is to engage with different payors to gain a sense of their processes and to help them understand our concerns and the challenges we’re experiencing. Recurrent issues include peer-to-peer review, backdated authorizations and payors’ interpretations of certain billing codes.

In the past, issues have arisen regarding specific types of treatments—typically the more technical or expensive ones. In the past, there was more leniency for approving commonly used treatments, but now payors are reviewing a broader range of services. Some payors are large entities with multiple offices and loca­tions, which can sometimes result in inconsistent interpretation of guidelines. Longer review times—up to 14 business days—lengthen the time to receive an approval before a patient’s treatment can proceed.

In meetings scheduled this year, we will present our members’ feedback to the payors. We have an opportunity to learn about respective challenges or pain points and gain a better understanding on both sides so that the reimbursement process can function more effectively. We’re also hoping to learn what providers can change to help expedite reimbursement. If we understand what payors want, we can take the information back to our members.

 We had a productive meeting with UnitedHealth­care (UHC) in April. We learned about UHC’s process, timelines, and how provid­ers can prepare for peer-to-peer reviews. We shared with UHC what providers’ expectations are and how they can make sure we know who should participate in the peer-to-peer review. We also discussed backdated authorizations. Providers need to help payors understand their processes and what work we can do prior to treatment.

From an operational standpoint, administrators may need extra resources, including staff to coordinate and ensure all required documents are complete and collated and any meetings are scheduled. Waiting for authorization from the payor can cause delays in payment for services as well as delays in starting treat­ment for a patient. Delays frustrate patients. Patients also worry if their treatment will be paid for or if they will have to pay out of pocket. By the time they reach radiation oncology, many patients have already accumulated expenses from surgery and/or chemotherapy.

We won’t be able to solve all the issues this year, but we aim to have a better understanding and a level of agreement and trust established so that we can continue to work through issues as they arise. All parties want to work together to improve the approval process and, ultimately, serve our patients better.

Submit Your Issues

Email de-identified examples of inappropriate use of prior authorization policies that have resulted in treatment delays and denials to healthpolicy1@astro.org. The SROA-ASTRO team will review your submission, follow up with any questions, and let you know the payor’s response once the meeting has taken place.

Q: What types of payor issues have you encountered?

Share any helpful tips and suggestions.

We would love to hear your experiences.

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