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Claims Payment Status for On-Pathway Navigations Across an Academic Cancer Center and its Network
Omar Waid, MBChB, MSHI; Andrew Reilly, MPS; Sarah Lippert, MBA, MPH; Alex Post; Matthew Rice; Joanna Hamilton, MA, MS; David M. Jackman, MD
Citation:
Abstract 1851538
Introduction
Delays in cancer treatment authorization impede optimal patient care. Dana-Farber Pathways gathers experts to create data-supported treatment recommendations that consider efficacy, toxicity, and cost for each point in a patient’s cancer journey. The concordance between on-pathway recommendations and payer approval decisions reflects the common ground shared between these two important sets of stakeholders.
Methods
Across the Dana-Farber Cancer Institute (DFCI), we have created and implemented a clinical pathways solution. Physicians at each of our campuses navigate the web-based decision support platform whenever making a new treatment decision. In this study, we retrospectively examined the detailed billing records for patients treated in accordance with pathway recommendations. This required manual review of charts, line-item billing requests, and payment status. To ensure claims were uniformly closed by the time of the analysis, our study focused specifically on on-pathway navigations for parenteral therapies with an associated claim request in January 2022.
Results
Of the 316 on-pathway navigations, 264 (83%) were paid in full upon initial billing (Table 1). In another 40 cases (13%), the anti-cancer agents were paid for, but payment for another element, such as bisphosphonate or granulocyte colony stimulating factor (G-CSF), was denied. Finally, of the remaining 12 on-pathway navigations, 11 treatments were ultimately paid for after the initial denials were overturned. The initial denial often pertained to process or timing rather than medical objection. Payment was fully denied in only 1 case (less than 1%).
This denial was for treatment in accordance with its US Food and Drug Administration (FDA) label; the denial was based on a request for additional information that wasn’t provided in time, not a medical objection.
Table 1. Claims Payments for Pathways and Non-Pathways
| Claims by Payment Status (N = 316) | Number (%) |
| Received full payment after initial billing | 264 (83) |
| Anti-cancer treatment paid for; payment for a non-pathways element (eg, bisphosphonate) denied | 40 (13) |
| Payment initially rejected due to non-medical reason; denial ultimately overturned | 11 (4) |
| Payment fully denied (due to non-medical reason) | 1 (< 1) |
Conclusion
In this retrospective assessment of payment rates, 315 out of 316 (99.7%) of on-pathway treatment orders were ultimately paid. This exceptionally high degree of concordance reflects the sound clinical expertise and judgement underlying Dana-Farber's data-driven pathways content. Pathways vendors and health care payers can use this concordance to iterate on workflows to minimize the time and effort currently required by the authorization process.
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