Insurance Denials Research Articles

Insurance Approval for Proton Therapy in Patients With Thoracic Malignancies: An Experience From a Cost-Neutral Payor Environment

<h3>Purpose/Objective(s)</h3> Despite the significant potential benefits, insurance approval for proton therapy to treat thoracic malignancies can be challenging, often requiring multiple layers of appeals process that adds significant burden of care while also delaying treatments. To increase insurance buy-in, at our institution we use an alternate payment model of cost-neutrality that charges intensity modulated proton therapy (IMPT) at the same rate as the standard of care photon-based IMRT/VMAT in a hospital setting. In this analysis, we seek to review success rates in obtaining insurance approval for IMPT when treating thoracic malignancies in our cost-neutral payor environment. <h3>Materials/Methods</h3> We performed a retrospective analysis of insurance approval records of patients with thoracic (lung, esophageal, thymic, mesothelial) malignancies for whom IMPT was recommended between years 2016-2020. Descriptive analyses were performed to obtain rates of insurance approvals and denials along with success rates of peer-to-peer (P2P) and appeals processes. <h3>Results</h3> In the study period, insurance approval data for 435 patients with thoracic malignancies who were offered IMPT was tracked. Tumor types for these patients were lung (263), esophageal (105), mesothelioma (37) and thymic (30) malignancies. The initial insurance approval rate without needing additional review was 80.9%. Of these, 222 (63.1%) patients had Medicare/Medicaid primary. For eight patients, an initial determination was not feasible since there was no mechanism for review with health plan. Among the 75 patients with initial denial, a P2P option was available only for 42 (56%) patients with successful reversal of denial in 28.5%. Of the remaining 30 patients with P2P denial, 1^st level of appeal overturned the denial in 8 (27%) patients with two more patients getting approved after additional levels of appeals. In the 33 patients where a P2P option was not available, treatment was approved in 6 (18%) patients at 1^st level of appeal. Due to clinical needs, six patients were approved by our financial team without a final determination assuming risk of denial. Option to submit a proton versus photon comparison treatment plan was available only in 16 of the 75 denied patients, of whom approval was granted in only 3 patients. Overall, the final approval was obtained in 386 (88.7%) patients. By disease site, final approval rate was 90.5% for esophageal, 89.3% for lung, 89.2% for mesothelial and 76.7% for thymic origin malignancies. <h3>Conclusion</h3> In this largest reported experience from a cost-neutral payor environment that charges IMPT at the hospital-rate of IMRT/VMAT, we note nearly 90% insurance approval rates for thoracic cancers with 80% of all patients avoiding the need for burdensome P2P and appeal processes. P2P option was available in only half of the patients with a success rate of less than 30%. Our analysis encourages institutions to explore the cost-neutral environment while urging payors to provide efficient and fair P2P and appeals process.

Transgender Youth Experiences with Implantable GnRH Agonists for Puberty Suppression.

This descriptive study reports caregiver experiences with GnRH agonist implants among a cohort of youth followed in a pediatric hospital-based gender clinic. We administered a survey to 36 of 55 eligible caregivers ascertaining demographics and satisfaction, with a medical record review of any surgical complications. The overwhelming majority (97.1%) reported satisfaction with the procedure and would undergo the implant procedure again (94.4%). The most frequent challenges noted were about affordability (39.8%) and insurance denials (39.8%). Implantable GnRH agonist can be used successfully in pediatric patients with gender dysphoria. Future policy should seek to address concerns regarding insurance approval and reimbursement.

Identifying gaps in the coverage of survivorship care services.

6583 Background: Despite advancements in reimbursement, anecdotal evidence suggests patients are not able to access guideline concordant survivorship care services due to a lack of coverage by payers. We present the results of a mixed methods study aimed to determine the practice-reported rates and sources of delay/denial on evidence-based, guideline concordant survivorship care services. Methods: A quantitative survey was developed by ASCO’s Cancer Survivorship Committee (CSC) to assess which services are being denied by payers for coverage/reimbursement. Questions were limited to disease sites for which practice guidelines exist. 533 ASCO members who provide survivorship care were surveyed, with a focus on obtaining representation from rural/urban, academic/private practice, pediatric/adult, and geographic location across the U.S. Semi-structured telephone interviews were conducted in October and November 2020 with geographic sub sample representation to further explore the nature of and extent to which coverage barriers are experienced for guideline-concordant care, specific to the provider or clinic’s primary disease site or specialty. Results: 120 responses from 50 states were included. Respondents were primarily clinicians (88%) with the majority treating patients with Medicare/Medicaid/CHIP (60%), followed by private/employer insurance (38%). There was little issue with coverage of hormone therapies. One-third reported issues some of the time with maintenance chemotherapy (38%) and immunotherapy (35%). Coverage denials for screening for recurrence for breast cancer (MRI, 63.5%), Hodgkin Lymphoma (PET/CT 47%; Breast MRI, 44.4%), and lung cancer (Low-dose CT 37.4%) were common. Half of the survey respondents reported denials for supportive care/symptom management services (Table). Private or employer-based insurance denials were most often the source of barriers (57.7%). Through interviews, denials were found to be the same across sites and not unique to a single payer or region. Most had a process to appeal denials for evidence-based services. Conclusions: Denial for survivorship care, particularly supportive care services, is common. There is a need for better advocacy with payers, improved policy, and support for providers/practices to implement protocols to obtain coverage for services, particularly in the face of burnout.[Table: see text]

Young Adult Populations Face Yet Another Barrier to Care With Insurers: Limited Access to Proton Therapy.

Young patients, including pediatric, adolescent, and young adult (YA) patients, are most likely to benefit from the reduced integral dose of proton beam radiation therapy (PBT) resulting in fewer late toxicities and secondary malignancies. This study sought to examine insurance approval and appeal outcomes for PBT among YA patients compared with pediatric patients at a large-volume proton therapy center. We performed a cross-sectional cohort study of 284 consecutive patients aged 0 to 39 years for whom PBT was recommended in 2018 through 2019. Pediatric patients were defined as aged 0 to 18 years and YA patients 19 to 39 years. Rates of approval, denials, and decision timelines were calculated. Tumor type and location were also evaluated as factors that may influence insurance decisions. A total of 207 patients (73%) were approved for PBT at initial request. YA patients (n = 68/143, 48%) were significantly less likely to receive initial approval compared with pediatric patients (n = 139/141; 99%) (P < .001). Even after 47% (n = 35 of 75) of the PBT denials for YA patients were overturned, YAs had a significantly lower final PBT approval (72% vs pediatric 99%; P < .001). The median wait time was also significantly longer for YA patients (median, 8 days; interquartile range [IQR] 3-17 vs median, 2 days; IQR, 0-6; P < .001). In those patients requiring an appeal, the median wait time was 16 days (IQR, 9-25). Given the decades of survivorship of YA patients, PBT is an important tool to reduce late toxicities and secondary malignancies. Compared with pediatric patients, YA patients are significantly less likely to receive insurance approval for PBT. Insurance denials and subsequent appeal requests result in significant delays for YA patients. Insurers need to re-examine their policies to include expedited decisions and appeals and removal of arbitrary age cutoffs so that YA patients can gain easier access to PBT. Furthermore, consensus guidelines encouraging greater PBT access for YA may be warranted from both medical societies and/or AYA experts.

Abortion attempts without clinical supervision among transgender, nonbinary and gender-expansive people in the United States

BackgroundTransgender, nonbinary and gender-expansive (TGE) people face barriers to abortion care and may consider abortion without clinical supervision.MethodsIn 2019, we recruited participants for an online survey about sexual and reproductive...

Consequences of insurance denials among U.S. patients prescribed repository corticotropin injection (Acthar Gel) for nephrotic syndrome

Introduction Repository corticotropin injection (RCI; Acthar Gel) is indicated to induce a diuresis or a remission of proteinuria in nephrotic syndrome (NS) without uremia of the idiopathic type or that due to lupus erythematosus. This study compares patient characteristics and measurable healthcare resource utilization (HCRU) between NS patients who received a prescription for RCI and then were either approved or denied treatment by their insurers. Methods A retrospective analysis of adults with NS from January 2015 to December 2018 was conducted using a de-identified open-source claims database. Patients were included in the study if they had ≥1diagnosis associated with NS, were age 18+, and had medical claims activity at some point in the year preceding (“baseline”) and year following (“follow up”) their first approved or denied RCI prescription. Baseline characteristics were reported with p-values indicating the significance of characteristics between cohorts. To assess outcomes, approved and denied patients were matched (1:1) using propensity-matching to account for underlying differences. Results Overall, 1,232 patients met inclusion criteria for the study. At baseline, approved patients were older than denied patients (mean age 53.9 vs. 48.4) and had higher rates of comorbidities. A greater proportion of approved patients required inpatient admissions (34.1 vs. 28.0%) and "high" doses of corticosteroids (CS) (26.2 vs. 20.7%) at baseline. Matched outcomes showed directionally more denied patients with inpatient admissions compared to approved (64 vs. 52) and a greater utilization of deep vein thrombosis ultrasound (12.2 vs. 6.6%) and dialysis (10.5 vs. 6.1%). Matched, denied patients had directionally greater CS use during follow-up both in the number of patients receiving CS (104 vs. 95) and the average annualized daily dose (4.1 vs. 3.4 mg). Conclusion Patients denied access to RCI treatment had directionally higher HCRU compared to matched, approved counterparts. Thus, the results of this study may aid providers and payers in evaluating scenarios where RCI may be beneficial and improve quality of care for NS patients.

UBH Ruling Called an Enormous Victory for Patients, Wake-Up Call to Insurers

UBH Ruling Called an Enormous Victory for Patients, Wake-Up Call to Insurers

Beyond the Hernia Repair: A Review of the Insurance Coverage of Critical Adjuncts in Abdominal Wall Reconstruction

Insurance companies were selected based on their national and state market share. Preauthorization criteria, preauthorization lists, and medical/clinical policies by each company for component separation, SVRH-P, and SVRH-A were examined. Coverage criteria were abstracted and analyzed. Fifty insurance companies were included in the study. Only 1 company had clear approval criteria for component separation, while 38 cover it on a case-by-case basis. Four companies had clear approval policies for SVHR-P, 4 cover them on an individual case basis, and 28 flatly do not cover SVHR-P. Similarly, 3 companies had clear approval policies for SVHR-A, 6 cover them case by case, and 33 do not cover SVHR-A. Component separation and soft tissue contouring are important adjunctive AWR procedures with efficacy supported by peer-reviewed literature. The variability in SVHR-P and SVHR-A coverage likely decreases access to these procedures even when there are established medical indications. The authors recommend standardization of coverage criteria for component separation, given that differing interpretations of medical necessity increase the likelihood of insurance denials.

Consequences of Insurance Denials Among U.S. Patients Prescribed Repository Corticotropin Injection for Acute Exacerbations of Multiple Sclerosis.

IntroductionRepository corticotropin injection (RCI; Acthar® Gel) is indicated for the treatment of acute exacerbations of multiple sclerosis (MS) in adults. Despite the well-documented clinical and economic benefits of RCI, many patients are denied use of the therapy by third-party payers. This study aims to understand the demographic and clinical characteristics of MS relapse patients who received a prescription for RCI from their physicians and then were either approved or denied treatment by their insurers. The study compares measurable clinical outcomes and healthcare resource utilization (HCRU) between approved and denied cohorts.MethodsA retrospective analysis of adults experiencing MS relapse from January 2015 to December 2018 was conducted using a de-identified open-source claims database [Symphony Health Integrated Dataverse® (IDV)]. Patients were identified using ICD codes for MS and considered to have relapsing/remitting type according to established claims-based methodology. Clinical characteristics and HCRU were analyzed during the year preceding (“baseline”) and the year following (“follow-up”) each patient’s index date, defined as the date of a patient’s first approved RCI claim (for patients with ≥ 1 approved claim) or first denied RCI claim (for patients with only denied claims). Baseline characteristics were reported with unadjusted differences and p values indicating the significance of characteristics between the two cohorts. For outcomes, match-adjusted results were reported using propensity matching to account for underlying differences between cohorts.ResultsThe study sample included 1902 MS relapse patients with at least one claim for RCI. At baseline, approved patients were slightly older compared to denied patients (mean age 48.0 vs. 47.2), had higher rates of hemiplegia/paraplegia (6.7% vs. 3.3%), greater mobility impairment (17% vs. 11.5%), more exacerbation episodes (66.2% vs. 59.9%), and a higher number of physical therapy/rehab claims (23.5 vs. 14.0), respectively. Outcomes among the matched sample show an increased use of corticosteroids for patients denied access to RCI compared to approved patients (51.1% vs. 42.4%), more exacerbation episodes (36.6% vs. 28.2%), and an increased number of physical therapy/rehab claims (11.5% vs. 9.9%), respectively.ConclusionThe results of this study may aid providers and payers in evaluating scenarios where RCI may be beneficial and improve quality of care for patients experiencing MS relapse.

Integrating fundamental cause theory and Bourdieu to explain pathways between socioeconomic status and health: the case of health insurance denials for genetic testing.

Fundamental cause theory (FCT) is among the most widely recognised and accepted social science frameworks used to examine the processes driving health inequalities. Despite the wide influence of the theory, it remains largely underutilised in practical and applied research on health disparities. This paper proposes that Pierre Bourdieu's theories of capital and symbolic power can be integrated with FCT to address limitations in the latter theory, making it more useful in health disparities research. Using a case study of U.S. health insurance claim denials for genetic testing among women with a breast cancer diagnosis, this work illustrates how the theoretical constructs of FCT and Bourdieu's work articulate, and consequently deepens our appreciation for the durable relationship between socioeconomic status and health. Study results reveal the multiple and complex mechanisms that play a role in access to healthcare services, which has significant implications for how we think about the role of health policy in addressing health disparities.

Insurance Denials in Reduction Mammaplasty: How Can We Serve Our Patients Better?

Reduction mammaplasty is the standard of care for symptomatic macromastia. The process of requesting insurance coverage for reduction mammaplasty is cumbersome and potentially controversial, and insurance policies vary significantly. The goal of our analysis is to identify trends in insurance coverage rates, assess for the presence of disparities, and propose ways to increase chances of successful preauthorization. The authors performed a retrospective review of preauthorizations for reduction mammaplasty at a single institution from 2012 to 2017. Insurance company names were deidentified. Preauthorization denial rates were assessed by year, insurance carrier, and reason for denial. Multiple regression analysis was performed to identify predictors for predetermination denial by insurance companies. Among 295 preauthorizations, 212 were approved (72 percent) and 83 were denied (28 percent), among which 18 were appealed, 13 successfully. Rates of insurance denials have been increasing steadily, from 18 percent to 41 percent. Medicaid had the lowest denial rates (9.3 percent), whereas private carriers denials ranged from 21.4 to 62.1 percent. In terms of reason for denial, 30 percent were because of contract exclusion, 39 percent were because of inadequate documentation or not meeting medical criteria, and 12 percent were because of inadequate predicted resection weight. Certain private insurance carriers were the only independent predictors of predetermination denial. Rate of preauthorization denials is high and has been increasing steadily. Insurance criteria remain arbitrary. A proper documentation and appeal process by the plastic surgeon may improve rates of insurance approval. Although resection weight does not correlate with symptom relief, predicted breast tissue resection weight continues to be critical for insurance approval.

Insurance Denials of Care Amount to Unlicensed Medical Practice.

No funding supported the writing of this article. The author has nothing to disclose.

Insurance Denials of NICU Hospital Claims

Insurance Denials of NICU Hospital Claims

Caregiver and Provider Experiences of Home Healthcare Quality for Children With Medical Complexity.

Despite a growing population of children with medical complexity, little is known about the current quality of pediatric home healthcare. The objective of this study was to characterize the quality of pediatric home healthcare experienced by primary family caregivers (parents) and healthcare providers of children with medical complexity. Semistructured, in-depth key informant interviews of 20 caregivers and 20 providers were conducted and analyzed for factors affecting home healthcare quality using the Institute of Medicine's quality framework (effective, safe, patient-centered, timely, equitable, and efficient). System complexity, insurance denials, and workforce shortages affected patients' ability to establish and maintain access to home healthcare leading to hospital discharge delays and negative family impacts. When home healthcare was accessible, respondents experienced it as effective in improving patient and family daily life and minimizing use of emergency and hospital services. However, respondents identified a need for more pediatric-specific home healthcare training and increased efficiencies in care plan communication. Overall, home healthcare was not perceived as timely or equitable due to access barriers. This study provides a new conceptual framework representing the relationship between home healthcare quality and outcomes for children with medical complexity for future evaluations of quality improvement, research, and policy initiatives.

Assessment of a Day Hospital Management Program for Children With Type 1 Diabetes

A shift in the setting of care delivery for children with a new diagnosis of type 1 diabetes led to a reorganization of treatment. To determine whether a new diagnosis of pediatric diabetes can be successfully managed in a day hospital model. This quality improvement study used retrospectively collected data on pediatric patients with a new diagnosis of diabetes who completed an inpatient program for education and insulin titration prospectively compared with patients completing a diabetes day hospital program. Baseline data were collected over 12 months (January-December 2015) and intervention data collected over 14 months (March 2016-May 2017). The study was conducted at a single institution and judged as a nonhuman participant project. The referral local base included a 100-mile radius. Patient inclusion was a new diagnosis of diabetes, age 5 years or older, and no biochemical evidence of diabetic ketoacidosis. Ninety-six patients completed the day hospital program and 192 patients completed an inpatient program. All patients received 2 consecutive days of insulin titration and education in either a day hospital or inpatient setting. Primary outcomes included the mean length of stay, patient charge, and insurance denial/reimbursement rates. The hypothesis was that a day hospital program would be associated with a reduced length of stay, which would directly affect patient charges and insurance denials. Among the 96 day hospital patients, the mean (SD) age was 12.2 (4.7) years (range 5-20.3), with no patients experiencing diabetic ketoacidosis or hypernatremia. Among the 192 inpatient patients, the mean (SD) age was 9.4 (4.7) years (range, 1.6-20.1). The mean (SD) length of stay reduction in the day hospital was 46 (14.1) to 14 (5.1) hours. The mean day hospital patient charge was $2800, compared with a mean (SD) baseline carge of $24 103 ($9401). Within the first year, there was a cumulative reduction in patient charges of more than $2.1 million. This study's findings suggest that a diabetes day hospital setting was associated with reductions in length of stay and patient charges, with an increase in insurance reimbursements and a decrease in insurance denials. This study demonstrates an effective way to streamline new-onset diabetes education, which may reduce length of stay and patient charges. Reimbursement rates for patients with a new diagnosis of diabetes increased from 52% to 72% and reimbursement denial rates decreased from 80% to 0%.

Transgender-Related Insurance Denials as Barriers to Transgender Healthcare: Differences in Experience by Insurance Type.

Insurance-based denials are common barriers for transgender and non-binary individuals in accessing medically necessary gender-affirming care. Little is known about how experiences of transgender-related insurance denials may vary by insurance type. This study investigates the association between transgender and non-binary individuals' experiences of different forms of transgender-related insurance denials and insurance type. The 2015 United States Transgender Survey was conducted by the National Center for Transgender Equality to ascertain US transgender and non-binary experiences across multiple life experiences, including individual health status, health services access and utilization, and experiences with denials. Multivariate logistic regressions were conducted, and adjusted risk ratios were calculated, to analyze the likelihood of experiencing eight different forms of denials by insurance type, including private, Medicare, Medicaid, and military-related, and having multiple types of insurance coverage. Models revealed significant relationships between transgender-related insurance denials and insurance type for 11,320 transgender and non-binary adults. Compared with those with private insurance, Medicaid coverage was associated with an increased likelihood of experiencing denials for hormone therapy (adjusted risk ratio (ARR)= 1.22; CI = 1.05-1.42; p = 0.02); having no in-network surgery providers was associated with Medicare (ARR = 1.84; CI = 1.29-2.62; p = 0.009) or Medicaid (ARR = 1.54; CI = 1.20-1.98; p = 0.003); and military-based insurance was associated with transition-related surgery denials (ARR = 1.53; CI = 1.36-1.72; p < 0.001). Researchers and practitioners must consider the link between type of insurance coverage and experiences with different forms of transgender-related insurance denial. These results provide continuing support for broad non-discrimination policy efforts, but also direct our attention to targeted insurance policy interventions by form of denial, which can promote equitable access for transgender and non-binary people across all healthcare needs.

The Forgotten Member of Patient Selection Committees: The US Constitution.

The Forgotten Member of Patient Selection Committees: The US Constitution.

Preservation of Organ Function after Transplantation for Sickle Cell Disease

Background Recipients of successful allogeneic hematopoietic stem cell transplant (HSCT) for sickle cell disease (SCD) have hemoglobin S levels that reflect those of the donor. SCD related organ damage targets vital organs and is variable based on age and disease severity, and can be further compromised by transplant related complications. Organ function parameters are generally not primary end-points for clinical trials but need longitudinal follow up. This study aims to describe organ function in transplant recipients followed for one or more years after HSCT for SCD. Methods Following Institutional Review Board approval, a retrospective chart review was undertaken of SCD patients >1-year from HSCT with donor engraftment. Demographic data and organ functions (lung, brain and eyes) pre, at one-year, and at most recent assessment were compared for each patient. Organ functions reviewed included, creatinine, brain imaging, intelligence quotient (IQ), pulmonary function, retinal examination, and ferritin levels. Results Twenty-two patients were included in this review. There were 10 matched sibling donor, 8 matched or mismatched unrelated donor, 1 haploidentical, and 3 cord blood transplant recipients. Four patients received repeat donor cell infusion for waning donor chimerism followed by stabilization. Median age at first HSCT was 10 years (range 4-21 years). Eleven patients had MRI changes pre-HSCT. At 1-year, 4 of 17 transplant recipients had new MRI changes (2 patients with PRES and 2 with worsening infarction). At last follow up 3 of 18 patients demonstrated new MRI changes: bilateral temporal mesial sclerosis (1) and silent infarcts (2). IQ testing was available both at baseline and anytime beyond 1 year in 7 patients. IQ improved or remained stable in 5 patients and was lower in 2 patients, but remained in the average range. Pulmonary function tests were available for 21 patients of which 4 patients had restrictive lung disease. Ferritin levels decreased in 13 of 18 patients beyond the first year post-HSCT. Ophthalmologic exams at baseline and after transplant were performed in 12 patients. While SCD retinopathy was detected at baseline in two patients, no retinopathy was noted after HSCT. Follow up is in progress for additional organs such as the heart and kidneys. Discussion Long-term follow up of SCD related parameters post-HSCT demonstrates the effect of the intervention on disease manifestations. Our data demonstrates stability or improvement in organ function in the majority of patients after HSCT. This retrospective analysis is limited by the lack of uniform assessment of SCD related parameters and by obstacles such as provider changes and insurance denials. Though our data indicates improvement in SCD parameters post-HSCT, it also underscores the importance of systematic follow up prospectively through clinical trials and registries following curative therapy for SCD.

Current state assessment survey of challenges of pharmacogenomics within oncology pharmacy practice.

The goal of this survey was to identify opportunities for health systems to increase implementation and adoption of oncology-focused pharmacogenomics services. An online survey assessing respondent demographics, baseline knowledge and training in pharmacogenomics, comfort level with pharmacogenomic data, and challenges of implementing clinical pharmacogenomic platforms was distributed to professional colleagues and over national oncology pharmacy listservs. Pharmacists were grouped based on their comfort level with pharmacogenomic data. Results were analyzed utilizing Pearson chi-square test. A p value of <0.05 was considered significant. A total of 84 participants from 58 cancer centers participated in the survey. Most participants were post-graduate year 2 trained and a majority reported being comfortable assessing oncology pharmacogenomic data. Respondents indicated that pharmacogenomics reported within the electronic medical record was the most common institutional process to support pharmacogenomics for oncology patients. Despite this, poor visibility of pharmacogenomics within the electronic medical record was the most challenging aspect of implementing a pharmacogenomic program. Additional challenges included lack of resources for pharmacogenomic programs, insurance denials for pharmacogenomic-driven testing and medication, and prolonged turnaround time of pharmacogenetic results. Length of practice, post-graduate year 2 residency training, institutions with pharmacist involvement on hematology/oncology molecular tumor board, and institutions where a pharmacist helped create local pharmacogenomic policies were significantly associated with respondents' comfortability in assessing pharmacogenomics. Oncology pharmacists reported substantial challenges in implementing a pharmacogenomic program. Future efforts to assist in developing pharmacogenomic efforts should focus on increasing pharmacist involvement, expanding education and training, and improving clinical decision support tools.

Court Ruling Against UBH Provides Roadmap for Fighting Insurance Denials

Court Ruling Against UBH Provides Roadmap for Fighting Insurance Denials