Optimizing Insurance Authorization and Sustainability in the Face of High-cost Novel Therapies



Poster Number: T394


Tiffany Lopez, Children's Hospital Colorado, Kaitlin Haug, BSN RN, Children's Hospital Colorado, Taylor Schwab, BSN RN, Children's Hospital Colorado, Scott Demarest, MD, MSCS, Children's Hospital Colorado, Julie Parsons, MD, Children's Hospital Colorado

Background: Since 2016, the FDA has approved several novel therapies for rare neuromuscular and neurogenetic diseases. Although these therapies have been life changing for patients and families, they come with significant cost. With each new approved therapy, it is essential for both the family and hospital, that these medications are approved and covered by insurance providers.

Objectives: Having the role of a designated operations program manager for the Complex Drugs Team ensures that complex, novel therapies are approved and delivered in a sustainable, safe and timely manner.

Methods: Prior authorizations were requested using drug specific workflows and submitting detailed packets to insurance companies. To minimize the time insurance companies take to do a case review, direct conversations with hospital leadership, pharmaceutical companies, and plan specific insurance case managers took place. When denials were received, peer-to-peer appeals were initiated and scheduled within 5 days.

Results: From October 2022 to October 2023, the operations program manager submitted 101 prior authorization requests for 82 unique patients with 10 different high-cost complex therapies. Of the 101 authorizations, 96 (95%) received approval on first submission. Of the 5 denials, 3 were appealed and overturned. Approvals were quickly obtained with 20 (19.8%) being obtained in 1 day or less, 61 (60.4%) between 2 and 14 days, and only 18 (17.8%) taking more than 14 days. The average time to secure an approval was 7.8 calendar days.

Conclusion: There are 10 complex novel therapies managed by Neurology Complex Drugs Program. With a dedicated operations program manager, the process of insurance submission was modified, and approval times have been decreased by an average of 69.5%. We are able to ensure more rapid time to treatment which improves patient and family satisfaction and outcomes.