Study: Prior Authorization for Elective Diagnostic Catheterization: The Value of Reviewers in Cases with Clinical Ambiguity

August 17, 2018

A study titled “Prior Authorization for Elective Diagnostic Catheterization: The Value of Reviewers in Cases with Clinical Ambiguity” was published in the June 2018 issue of American Health & Drug Benefits. The study’s lead author, Adam C. Powell, Ph.D., and his team sought to identify the outcomes of HealthHelp’s two-step approach to evaluating the appropriateness of elective diagnostic catheterization orders. The research was conducted in conjunction with Humana, as a part of the ongoing research alliance between the two organizations. The study analyzed elective diagnostic catheterization orders placed in 2015 for patients with Humana Medicare Advantage health plans.

In some situations, evidence-based guidelines cannot provide definitive guidance on the appropriateness of diagnostic catheterization. HealthHelp utilizes a two-step approach to address this ambiguity. HealthHelp first evaluates the appropriateness of diagnostic catheterization orders using a rule-based decision support system, and then has reviewers provide input through its consult system. The consult system has ordering physicians discuss their orders with peer physicians when they appear to be nonindicated or inadequately justified. The discussion is intended to be educative in nature, and always provides ordering physicians with authorization to proceed with the catheterization – even in circumstances in which peer physicians do not reach a consensus with ordering physicians regarding the decision.

The study analyzed a population of 3,808 orders for elective diagnostic catheterization. Most (72.6%) of the orders were deemed potentially appropriate by the rule-based system; such orders were approved 99.1% of the time. Nonetheless, orders that were deemed by the rule-based system to have inadequate initial justification or to be potentially nonindicated were usually ultimately approved by the consult system. Orders deemed to have inadequate initial justification were approved by the consult system 72.8% of the time, and orders deemed to be potentially nonindicated were approved by the consult system 86.7% of the time.

Chi-square tests did not show a significant association between plan type or physician specialty and the classification produced by the rule-based system or the consult system. The patients’ state of residence was significantly associated with the classification of orders for the rule-based system, but not for the consult system.

Rule-based decision support can be combined with consult-based peer discussion to determine whether care is appropriate when guidelines are ambiguous. The results suggest that many poorly justified orders are supportable after more information on the patient’s presentation is provided.

Reflecting upon the study, Dr. Powell remarked, “These findings help show the importance of HealthHelp’s integration of both a rule-based approach and a peer consult-based approach to nondenial prior authorization. The use of a rule-based approach to initially evaluate orders enables HealthHelp to be judicious in its use of peer consults. Referring elective diagnostic catheterization orders that at first glance appear to be either nonindicated or inadequately justified to peer consult helps ensure that patients get catheterizations when they need them – while also educating ordering physicians about why some patients may not be in need of catheterizations. Our findings show that orders that initially appeared to be nonindicated or inadequately justified were a mixed bag – after they were discussed during peer review, some were considered to be necessary and some were not.”

American Health & Drug Benefits invited Raymond L. Singer, MD, Physician-in-Chief of the LVHN Special Surgery Institute at the Lehigh Valley Health Network, to write a companion article in reaction to the piece. His stakeholder perspective, titled, “Standardized Documentation Can Improve Diagnostic Testing Decisions for Patients with Cardiovascular Disease”, stated, “Ensuring judicious ordering while protecting patients who need care is truly a win-win approach.”

To read the articles by Dr. Powell’s team and by Dr. Singer, visit http://ahdbonline.com/issues/2018/june-2017-vol-10-no-4/2580-prior-authorization-for-elective-diagnostic-catheterization-the-value-of-reviewers-in-cases-with-clinical-ambiguity

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