Evaluating proactive outreach for prior authorization recertifications in Medicaid patients

2021 ◽  
Vol 27 (11) ◽  
pp. e395-e399
Keyword(s):  
Prior Authorization

Prior Authorization

2010 ◽  
Vol 43 (14) ◽  
pp. 49
Author(s):  
JOSEPH S. EASTERN
Keyword(s):  
Prior Authorization

807 Diagnostic Pathways of Patients Authorized for Obstructive Sleep Apnea Testing and Treatment: A Retrospective Claims Analysis

SLEEP ◽  
2021 ◽  
Vol 44 (Supplement_2) ◽  
pp. A315-A315
Author(s):  
Binh Nguyen ◽  
Aliza Gordon ◽  
Stefanida Blake ◽  
Lakshmi Kalluri ◽  
Winnie Chi ◽  
...  
Keyword(s):  
Obstructive Sleep Apnea ◽  
Laboratory Testing ◽  
Diagnostic Testing ◽  
Prior Authorization ◽  
Home Test ◽  
Home Testing ◽  
Obstructive Sleep ◽  
Osa Treatment ◽  
Diagnostic Pathways ◽  
Lab Test

Abstract Introduction Obstructive Sleep Apnea (OSA) has been shown to reduce health-related quality of life and is associated with cardiovascular disease and other negative health outcomes. However, many patients with suspected OSA are never tested, thereby remaining undiagnosed and untreated. In this study, we explore the diagnostic pathways and eventual treatment of individuals with suspected OSA. Methods We conducted a retrospective, observational study, linking claims and prior authorization data of a large, geographically diverse health insurer’s commercial and Medicare Advantage members. Our sample included adults with suspected OSA and no prior OSA history, whose diagnostic testing had been approved through prior authorization (N=75,011). Using a 3-month time window following authorization, we searched for a claim to match the authorized service (home or laboratory sleep testing). We also looked for subsequent prior authorization for OSA treatment (Positive Airway Pressure (PAP) or oral appliance) and corresponding claims for those treatments within the 3-month authorization window. Results Among the study sample (N=75,011), 40,002 (53.3%) had home testing only, 17,319 (23.1%) had laboratory testing only, and 6,053 (8.1%) had a home test followed by a laboratory test. Only 476 (0.6%) had a home test after the date of a lab test. 11,161 individuals (14.9%) did not complete any sleep test. Of the 63,850 individuals with any sleep testing, 39,062 (61.2%) received prior authorization for initiating OSA treatment, and 36,158 (92.6%) of them had a corresponding claim for treatment. Conclusion One in eight adults with suspected OSA for whom diagnostic testing was authorized did not undergo testing; among those who tested, home testing was most common. While it is clinically appropriate to follow a negative home test with a lab test since a home test cannot rule out OSA (only confirm it), the study notes that a significant number of those with a home test require follow-up laboratory testing. Together, this represents an opportunity for reducing barriers to testing and improvement in home testing technology. Support (if any) This study was funded by Anthem, Inc.

What Is the Impact of Prior Authorization on the Incidence of Pediatric Tonsillectomy?

2020 ◽  
pp. 019459982096963
Author(s):  
Vanessa F. Torrecillas ◽  
Kaden Neuberger ◽  
Alexander Ramirez ◽  
Paul Krakovitz ◽  
Jeremy D. Meier
Keyword(s):  
Elective Surgery ◽  
Lag Time ◽  
Cross Sectional Study ◽  
Health Claims ◽  
Third Party ◽  
Prior Authorization ◽  
Cross Sectional ◽  
Before And After ◽  
The Mean ◽  
The Impact

Objective Third-party payers advocate for prior authorization (PA) to reduce overutilization of health care resources. The impact of PA in elective surgery is understudied, especially in cases where evidence-based clinical practice guidelines define operative candidacy. The objective of this study is to investigate the impact of PA on the incidence of pediatric tonsillectomy. Study Design Cross-sectional study. Setting Health claims database from a third-party payer. Methods Any pediatric patient who had evaluation for tonsillectomy from 2016 to 2019 was eligible for inclusion. A time series analysis was used to evaluate the change in incidence of tonsillectomy before and after PA. Lag time from consultation to surgery before and after PA was compared with segmented regression. Results A total of 10,047 tonsillectomy claims met inclusion and exclusion criteria. Female patients made up 51% of claims, and the mean age was 7.9 years. Just 1.5% of claims were denied after PA implementation. There was no change in the incidence of tonsillectomy for all plan types ( P = .1). Increased lag time from consultation to surgery was noted immediately after PA implementation by 2.38 days (95% CI, 0.23-4.54; P = .030); otherwise, there was no significant change over time ( P = .98). Conclusion A modest number of tonsillectomy claims were denied approval after implementation of PA. The value of PA for pediatric tonsillectomy is questionable, as it did not result in decreased incidence of tonsillectomy in this cohort.

National benchmarks and practice level variation on eight cross cutting quality measures.

2021 ◽  
Vol 39 (28_suppl) ◽  
pp. 255-255
Author(s):  
Tracy E. Spinks ◽  
Lindsey Bandini ◽  
Amie Cook ◽  
Hong Gao ◽  
Nicholas Jennings ◽  
...  
Keyword(s):  
Quality Of Care ◽  
Performance Status ◽  
Gynecologic Oncology ◽  
Quality Measures ◽  
Surgical Oncology ◽  
Small Sample ◽  
Prior Authorization ◽  
Level Variation ◽  
Practice Level

255 Background: While there is increased attention on the importance of quality measurement in oncology, especially with the rise of value-based payment, limited data exist on national averages and practice level variation for proposed quality measures to establish benchmarks and targets for quality improvement initiatives or value-based contracts. Methods: UnitedHealthcare (UHC) developed peer comparison reports for eight cross cutting quality measures for practices with an active contract for at least one of its commercial, Medicare or Medicaid health plans and ≥1 provider from the following specialties: gynecologic oncology, hematology/oncology, pediatric hematology/oncology, radiation oncology, or surgical oncology. Adherence to the quality measures below was calculated using a mix of claims data, clinical data from a prior authorization for cancer therapy, and CMS MIPS data. Patients were attributed through an algorithm that selected the most probable physician responsible for the patient’s care - responsible prior authorization provider, servicing provider or most recent visited provider prior to the treatment, varying by each measure. Dates of service differ by measure, ranging from 1/1/2019 through 12/31/2020. Results: We identified 5,828 unique tax identification numbers (TINs) with UHC members with cancer attributed to them during 2019-20. The number of practices included in the measurement cohort per measure varied significantly from 301 to 4,120 (tobacco screening and performance status, respectively). 2,422 TINs met the minimum patient count for at least one measure (≥10 patients or events). Overall performance ranged from 13.5% to 77.3% (hospice admission and PS documented) for measures where higher adherence reflects better quality of care. For measures where lower scores represent higher quality of care the range was 11.4% to 22.6% (hospice < 3 days and ED admission, respectively). Observed adherence was statistically better than expected for 0.5%-5.8% and statistically less than expected for 0.9%-5.6% of TINs in UHC’s network; however, more than half of the practices had insufficient sample size to make a determination. Conclusions: We observed substantial variation in quality across a national cohort of oncology practices. However, even for a large national payer, small sample sizes limited the assessment of a substantial number of practices.[Table: see text]

Abstract 9: Alirocumab Prior Authorization Approval and Prescription Fill Rates Among Medicare Advantage Patients in a Large US Managed Care Plan

2018 ◽  
Vol 11 (suppl_1) ◽  
Author(s):  
Kelley C Dacus ◽  
Libby Horter ◽  
Jennifer Hayden ◽  
Raymond A Harvey ◽  
Stephen Thompson ◽  
...  
Keyword(s):  
Prescription Drug ◽  
Low Income ◽  
Care Plan ◽  
Atherosclerotic Cardiovascular Disease ◽  
Prior Authorization ◽  
Medicare Advantage ◽  
Pcsk9 Inhibitor ◽  
Prescription Claim ◽  
Pharmacy Claims ◽  
Dual Eligibility

Introduction: Alirocumab is a proprotein convertase subtilisin/ kexin type 9 (PCSK9) inhibitor approved as an adjunct to diet and maximally tolerated statin therapy for treatment of adults with heterozygous familial hypercholesterolemia (HeFH) or clinical atherosclerotic cardiovascular disease who require additional lowering of LDL-cholesterol. Barriers to possession, including therapy cost and cost-sharing implications, may contribute to low utilization of this therapy. Objective: To explore differences in demographic and clinical characteristics between patients with prior authorization (PA) approvals or denials for alirocumab as evidenced through filled alirocumab prescription claims. Methods: A retrospective claims-based database analysis of patients with a Medicare Advantage Prescription Drug (MAPD) plan was conducted to identify patients with evidence of a PA approval for alirocumab. Among the group of patients with a PA for alirocumab, the pharmacy claims database was searched for evidence of a corresponding prescription claim within 30 days following the first PA request (index date). The analysis was stratified by evidence of Federal low income subsidy (LIS) support, a program that provides extra assistance with prescription drug costs for eligible individuals whose income and resources are limited, and/ or dual eligibility (DE) status, eligible for Medicare and Medicaid, (LIS/DE) at index. Results: A total of 2,098 MAPD patients meeting study inclusion/exclusion criteria and with a PA for alirocumab were identified between March 1, 2016 and February 28, 2017. Non-LIS/DE patients comprised approximately 82% of the eligible population (n=1,730). There were several notable differences in baseline demographics between the non-LIS/DE vs. the LIS/DE cohorts with an approved PA claim, including Deyo-Charlson Comorbidity Index (2.2 vs. 3.0), prevalence of diabetes mellitus (39.2% vs. 54.7%), and prevalence of HeFH (11.8% vs. 15.6%). While the percentage of patients with an approved PA was similar between the LIS/DE and non-LIS/DE cohorts, 88.9% and 91.2%, respectively, substantially more patients in the LIS/DE cohort had evidence of alirocumab possession based on a paid claim (60.6%) vs. those in the non-LIS/DE cohort (17.3%). Conclusion: Although a high percentage of MAPD patients had evidence of an approved PA, there were notable differences in clinical and demographic characteristics between those with and without LIS/ DE status. Further, the proportion of patients with an approved PA and a paid prescription claim differed markedly amongst MAPD patients with and without LIS/DE status, suggesting further research is needed to understand potential barriers to obtaining PCSK9i therapy.

scholarly journals Fluoridation of the public water supply and prevalence of dental fluorosis in a peripheral district of the municipality of Bauru, SP

2006 ◽  
Vol 14 (2) ◽  
pp. 136-141 ◽  
Author(s):  
Irene Ramires ◽  
Kelly Polido Kaneshiro Olympio ◽  
Andréa Gutierrez Maria ◽  
Juliano Pelim Pessan ◽  
Vanessa Eid Silva Cardoso ◽  
...  
Keyword(s):  
Water Supply ◽  
Water Samples ◽  
Dental Fluorosis ◽  
Fluoride Concentration ◽  
Epidemiological Survey ◽  
Public Water Supply ◽  
Prior Authorization ◽  
The Public ◽  
Electrode Method ◽  
Sensitive Electrode

OBJECTIVES: The objectives of this study were to assess the fluoride concentration in the public water supply and the prevalence of dental fluorosis in schoolchildren between 7 and 15 years old, living in a peripheral district of the municipality of Bauru. MATERIAL AND METHODS: For this, fifty two water samples were collected on three different days of one week. These samples were analyzed for fluoride by means of the ion-sensitive electrode method (Orion 9609) coupled to a potentiometer (Procyon, model 720). In this method, 1.0 mL of TISAB II (Orion) was added to 1.0 mL of the sample. For the epidemiological survey of fluorosis, 52 schoolchildren of both genders, aged between 7 and 15 were assessed, with prior authorization from their caretakers. Only one person examined the children, after supervised toothbrushing and drying with cotton wool rolls. The TF index was used. RESULTS: The fluoride concentrations in the water samples ranged from 0.62 to 1.20 mg/L, with a mean of 0.9 mg/L. The prevalence of dental fluorosis was 33%, with severity ranging from TF1 to TF4 (Kappa of 0.73 and concordance of 83.33%). CONCLUSIONS: The results from the analysis of water samples indicated a fluoride concentration greater than recommended for Bauru. The fluorosis levels found were higher than expected for a peripheral district, in which water is one of the few sources of fluoride.

Fundamental Freedoms Strengthen the Rights of Patients (again)

2012 ◽  
Vol 3 (2) ◽  
pp. 261-263
Author(s):  
Alexander Weiss
Keyword(s):  
Member State ◽  
Medical Care ◽  
Prior Authorization ◽  
National Legislation ◽  
Hospital Medical ◽  
Fundamental Freedoms

Case C-255/09 Commission v PortugalThe Portuguese Republic has failed to fulfil its obligations under Article 49 EC (Article 56 TFEU) by making no provision for reimbursement of non-hospital medical care provided in another Member State which does not involve the use of major and costly equipment exhaustively listed in the national legislation, other than in the circumstances specified in Regulation (EEC) No 1408/71 […] or, to the extent that Decree-Law No 177/92 allows reimbursement in respect of such care, by making such reimbursement subject to prior authorization (official headnote).

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