April 14, 2017
A poster for the study “Prior Authorization for Diagnostic Catheterization: The Value of Reviewers When there is Clinical Ambiguity” was presented at the 2017 American Heart Association Quality of Care and Outcomes Research meeting from April 2-3, 2017, in Arlington, Virginia.
The study’s lead author, Dr. Adam C. Powell, and his team sought to examine how the rule-based and consult-based components of a specialty benefits management program determined the appropriateness of diagnostic catheterization orders placed for patients in the Medicare Advantage health plans of one national insurer in 2015. Dr. Powell and his team used 2015 administrative prior authorization data from individuals who had health care coverage from Humana, aligned with the cardiology specialty benefits management program offered by HealthHelp, a WNS company.
HealthHelp’s rule-based decision-support system deemed most orders (72.6 percent) potentially appropriate. HealthHelp’s consult system, which involves clinical reviewers, nearly always approved these orders as well. Orders with inadequate initial justification were the least likely to be approved by the consult system, although the majority were ultimately approved after a peer-to-peer conversation with a HealthHelp consult physician. Additionally, the consult system resulted in the approval of most orders initially deemed potentially nonindicated. These findings show that obtaining additional information after an order is submitted, including utilizing peer-to-peer consultation if needed, can help ensure that all patients receive necessary and appropriate diagnostic tests.
In addition to characterizing outcomes from the prior authorization process, the study investigated potential differences between populations of patients. No significant association was detected between a patient’s health plan type and the determination of the rule-based system (P = .18) or the consult system (P = .10). Also, there was no significant association between the ordering physician’s specialty and the determination of the rule-based system (P = .89) or the consult system (P = .57). There was a significant association between the classification of the order by the rule-based system and the state of residence of the patient (P < .001). However, the association between the classification of the order by consult system and the state of residence was not significant (P = .73).
For more information on the American Heart Association’s Quality of Care and Outcomes Research meeting, visit the website.