Project Overview

Problem:

• Payers vary widely on how prior authorization for cancer therapy is accomplished.  Some use a web portal for oncologists to enter data into an electronic form.  Others use oncology clinical pathways to develop a proposed treatment option. Despite the method, many prior authorization processes among payers rely on manual inspection, with no automation or standard interface to health systems.
• Prior authorization imposes a burden on patients, providers and payers
• Current manual processes require duplicate data entry, are costly and may delay treatment 

Description:

• There is national interest, both in industry and the federal government, for standardization of the prior authorization process. The goal is reduction of costs by automation and standardization of health system-to-payer prior authorization interaction.  This has the potential to greatly reduce oncologist burden, which is a known factor in physician burnout.

Target Outcome:

• Provide a standard method to supplement the Da Vinci Coverage Requirements Discovery (CRD), Document Template Rules (DTR) and Prior Authorization Support (PAS) FHIR-based information exchange framework with cancer specific data as defined by mCODE, to enable prior authorization auto-approvals.
• Base the solution on approaches referenced in CMS Proposed rules
  • December 2022 Proposed rule CMS Advancing Interoperability and PA Rule
  • December 2020 Proposed rule CMS interoperability rules.  
• Reduce clinician, health system, patient and payer burden

Value:

• Patients receive timely care without delay because prior authorization turnaround time is reduced
• Provider burden reduced with automated approvals, and real-time access to payer approval requirements and documentation rules
• Payer burden is reduced by automating manual processes using a standardized information exchange 

Equity:

The CodeX Prior Authorization in Oncology are committed to supporting an equitable health care system and have committed to the Federal Moonshot initiative.  

We believe that improving and automating the prior authorization process for patients, providers and payers can result in timely delivery of appropriate and high-quality care.  With timely delivery of care, we can assist in curing and/or prolonging the life of a patient and optimizing the patient’s quality of life.

Commitment #1: Define, model and scaling an automated prior authorization process for cancer patients via the use of FHIR-based healthcare data standards to extract and exchange the necessary information to expedite the prior authorization process for cancer patients and reduce burden for providers and payers. These data standards include the clinical specialty data standards (mCODE representing oncology data, and RTTD representing radiation therapy data) as well the Da Vinci FHIR standards addressing value-based care transactions including those needed for prior authorization. Clinical specialty data standards such as mCODE are essential to ensuring accurate clinical representation for the decision support needed to ensure correlation of the right treatments to the right cancer patients.

Commitment #2: In alignment with industry technical and data standards, modify or create as necessary, open-source technical specification(s) documenting the workflow and criteria necessary to expedite the prior authorization in oncology process.

Commitment #3: Implement the Prior Authorization in Oncology FHIR driven real-time process with point-of-care decision support for stakeholders to assist in expediting care for cancer patients.

Commitment #4:   Capture metrics through this use case in hopes of providing additional insights and learnings that can potentially be applied to informing new best practice in prior authorization in oncology as well as reduction of burden for patients, providers, and payers.

Project Plan

Conference Call Schedule & Dial-Ins

CodeX: Oncology Prior Auth Use Case Public Calls 

The Last Tuesday, every other month - 3:00 - 4:00 EST

• January 31, 2023
• March 28, 2023
• May 30, 2023
• July 25, 2023
• September 26, 2023

Meeting Details:

Register in advance for this meeting:

https://hl7-org.zoom.us/meeting/register/tJwpf--hpz0rH9U8X8uOO4O8WosEnCX--RoS 

After registering, you will receive a confirmation email containing information about joining the meeting.

Reach out to Kim Boyd (kim.boyd@pocp.com) to be added to the invitation and received updates and modifications to call schedules.