Prior authorization
Keeping oncology prior authorizations from stalling after the visit
A prior authorization begins in the exam room and stalls afterward, when the order is in the note and nobody owns the next step. OncoNexus works with community oncology practices to give each authorization task from a visit a suggested owner and due date. Your provider approves them, and your team carries them out.
What one cancer center's records showed
A published review from Fox Chase Cancer Center looked at 149 oral anticancer drug prescriptions for 116 patients with prostate or kidney cancer, written between August 2014 and August 2015.1
- 109 of the prescriptions (73%) took two or more phone calls.
- 60 of them (40%) took five or more calls to get prior authorization, financial assistance or patient instructions.
- The median time from prescription to the patient receiving the drug was 12 calendar days.
- Financial assistance was used for 54% of the 107 prescriptions with data on it. Those prescriptions took longer to fill and needed more calls.
The authors note that about half of staff calls involved prior authorization and insurance barriers. This was one center's retrospective review from a few years ago, and your clinic's numbers may look different. That is why the pilot measures your own.
Six handoffs between prescription and first dose
Practices handle these differently. Each one needs a person and a date.
The order
The provider prescribes the drug, and the plan names who starts the paperwork.
The authorization request
Someone gathers the records and sends the request to the payer.
The payer's answer
Someone checks the status and responds if the payer asks for more.
Financial help
If the co-pay is out of reach, someone applies for assistance.
The pharmacy
A specialty pharmacy dispenses the drug and arranges delivery. Someone confirms it has the prescription.
The patient
Someone calls to confirm the drug arrived and the patient knows how to start.
When two or more of these sit with different people, each can end up waiting on the next. Picture a prescription written on a Monday in a packed week. The authorization slips. Three weeks later, the patient calls to ask why treatment hasn't started.
What OncoNexus does, and what it doesn't
OncoNexus drafts the action plan from the recorded visit, and each of those handoffs can be a task on it. Each task gets a suggested owner and a due date. Authorization tasks are suggested to your billing or authorization staff. When a request needs clinical documentation, OncoNexus can add a linked task for the provider. Your provider reviews and approves the plan, and your team can see what is still open.
OncoNexus does not submit authorizations or contact payers or pharmacies. Your team does that work. What changes is that each step is written down, someone owns it, and it has a date.
What the pilot measures
During the 3-month pilot, we track chase time, callbacks and rework with your team, including how long authorization tasks stay open and how many calls they take. You can compare that with how things run today and judge the results yourself.
Questions clinics ask
Does OncoNexus submit prior authorizations?
No. OncoNexus drafts the plan and puts the authorization on it as a task with a suggested owner and due date. Your team submits it and follows up with the payer.
How long do oral cancer drug authorizations take?
It varies by drug, payer and clinic. In a review of 149 oral anticancer prescriptions at Fox Chase Cancer Center (Geynisman et al., 2018), the median time from prescription to the patient receiving the drug was 12 calendar days.
Who should own a prior authorization task?
Practices handle it differently. Some assign it to a nurse navigator, a medical assistant or a dedicated authorization specialist. OncoNexus suggests your billing or authorization staff, and when the request needs clinical documentation it can add a linked task for the provider. Your provider can change either owner, and the plan shows who has it.
What should a clinic track?
Calls per prescription, how long each authorization task stays open, and the days from prescription until the patient has the drug. The pilot tracks the first two with your team.
More on how we work with clinics
A 3-month pilot for community oncology practices.
1 to 5 providers, whatever your clinic's size. No charge, with hands-on support. Clinics in the pilot get a discounted price after it ends.