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- Title
Insurance Denials and Patient Treatment in a Large Academic Radiation Oncology Center.
- Authors
Shin, Jacob Y.; Chino, Fumiko; Cuaron, John J.; Washington, Charles; Jablonowski, Margaret; McBride, Sean; Gomez, Daniel R.
- Abstract
Key Points: Question: Is insurance denial associated with radiation oncology treatment? Findings: In this single-institution cohort analysis of 206 cases, most insurance denials in radiation oncology were ultimately reversed on appeal; however, radiation therapy technique and/or effectiveness may be compromised by payer-mandated changes with resultant delays, reduced dose, or less conformal treatment delivery. Meaning: These findings suggest that further investigation and action are needed to recognize the time and financial burdens on clinicians as well as the patient outcomes associated with insurance denials of radiation treatments. This cohort study assesses insurance denials of radiation therapy and their association with changes in radiation technique, dose, and time to treatment delivery among patients with cancer. Importance: Insurance barriers to cancer care can cause significant patient and clinician burden. Objective: To investigate the association of insurance denial with changes in technique, dose, and time to delivery of radiation oncology treatment. Design, Setting, and Participants: In this single-institution cohort analysis, data were collected from patients with payer-denied authorization for radiation therapy (RT) from November 1, 2021, to December 8, 2022. Data were analyzed from December 15, 2022, to December 31, 2023. Exposure: Insurance denial for RT. Main Outcomes and Measures: Association of these denials with changes in RT technique, dose, and time to treatment delivery was assessed using χ2 tests. Results: A total of 206 cases (118 women [57.3%]; median age, 58 [range, 26-91] years) were identified. Most insurers (199 [96.6%]) were commercial payers, while 7 (3.4%) were Medicare or Medicare Advantage. One hundred sixty-one patients (78.2%) were younger than 65 years. Of 206 cases, 127 (61.7%) were ultimately authorized without any change to the requested RT technique or prescription dose; 56 (27.2%) were authorized after modification to RT technique and/or prescription dose required by the payer. Of 21 cases with required prescription dose change, the median decrease in dose was 24.0 (range, 2.3-51.0) Gy. Of 202 cases (98.1%) with RT delivered, 72 (34.9%) were delayed for a mean (SD) of 7.8 (9.1) days and median of 5 (range, 1-49) days. Four cases (1.9%) ultimately did not receive any authorization, with 3 (1.5%) not undergoing RT, and 1 (0.5%) seeking treatment at another institution. Conclusions and Relevance: In this cohort study of patients with payer-denied cases, most insurance denials in radiation oncology were ultimately approved on appeal; however, RT technique and/or effectiveness may be compromised by payer-mandated changes. Further investigation and action to recognize the time and financial burdens on clinicians and clinical effects on patients caused by insurance denials of RT is needed.
- Subjects
CANCER treatment; HEALTH insurance reimbursement; INSURANCE; RADIOTHERAPY; ACADEMIC medical centers; RESEARCH funding; CANCER patient medical care; MEDICAL care; MEDICARE; ONCOLOGY; CHI-squared test; DESCRIPTIVE statistics; LONGITUDINAL method; RADIATION doses; DATA analysis software; TIME; SPECIALTY hospitals; INSURANCE companies
- Publication
JAMA Network Open, 2024, Vol 7, Issue 6, pe2416359
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2024.16359