Is prior authorization for endovenous procedures cost effective?

March 2, 2020

Congratulations to Dr. Victoria Lee, vascular surgeon and Associate Medical Director of Syntactx, for being first author in, “Prior authorization as a utilization management tool for elective superficial venous procedures results in high administrative cost and low efficacy in reducing utilization”, published in the Journal of Vascular Surgery: Venous Lymphatic Disorders. Endovenous therapies is among the fastest growing areas of endovascular surgery and is a focus of Dr. Lee’s experience and expertise.

Prior to joining Syntactx, Dr. Lee was the first resident in the New York University School of Medicine Integrated Vascular Surgery Residency Program where she trained under Dr. Mark Adelman, former Chief of Vascular Surgery at NYU and now Chief Medical Officer of Syntactx. Dr. Lee participated in a number of clinical studies on vascular and endovascular therapies at NYU, including endovenous therapies. She also complemented her medical training with work in healthcare resource utilization management.

Overlap of that work with the clinical expertise provided by her colleagues from the Division of Vascular Surgery at New York University Langone Medical Center are described in the following abstract. This discusses the efficacy of prior authorization applied to in-office lower extremity superficial venous procedures performed at their institution.

Read on to take a look, and ask how we can support any clinical and regulatory work for your endovenous products. This paper and many other publications authored by our Syntactx physicians and professionals are evidence of the therapeutic expertise we offer to clients.

Abstract

Objective: Prior authorization (PA) is a process used by payers for safety and cost savings purposes, but it has received criticism for being time-consuming and costly because of administrative burden. Our study evaluated efficacy of PA applied to in-office lower extremity superficial venous procedures.

Methods: All in-office lower extremity venous procedures scheduled to be performed at our institution in 2017 were included in the study. Variables of interest were type of procedure, initial PA status (approved or denied), rationale for the decision, and final status after appeal. Cost analysis was performed using Centers for Medicare and Medicaid Services allowable rates to approximate billing and reimbursement data (proprietary) as well as calculated using industry averages.

Results: For 2017, of 1959 procedures scheduled, 57.9% (n = 1134) required PA. Of these, only 6.1% (n = 69) received initial PA denial, and nearly 40% of the denials (n = 27) were overturned after appeal. Of the 42 denials that were upheld, 15 resulted in cancellations; the remainder were performed by patient self-pay (n = 11) or by the provider pro bono (n = 16). Overturned denials were a result of either submission of incomplete clinical data on initial PA request or insufficient documentation of clinical necessity. When Centers for Medicare and Medicaid Services allowable rates were applied for cost analysis, the denials resulted in <$60,000 payer savings. Administrative expenses totaled >$110,000 when industry standards were applied, which far exceeds any calculated payer savings using the same methods. The 15 denials resulting in procedure cancellations (1.3% of all PAs) could be considered a net savings to the health care system but only approximated a mere $30,000.

Conclusions: Our study demonstrates that PA is not a cost-effective measure for utilization management of outpatient superficial venous procedures when surgeon practices are already well aligned with insurance guidelines. For these physicians and physician groups, the administrative cost associated with the PA process exceeds the savings seen by the insurance companies.

Lee V, Berland T, Jacobowitz G, Rockman C, Sadek M, Barfield M, Cayne N, Maldonado T. J Vasc Surg Venous Lymphat Disord. 2019 Dec 17. In press.