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Full text release has been delayed at the author's request until December 10, 2024

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Frequency of Test Approval after Preauthorization, Peer-to-peer, Appeal Letter, and Independent External Review: A Retrospective Chart Review

O'Sullivan, Colleen
http://orcid.org/0000-0003-1559-0587
http://rave.ohiolink.edu/etdc/view?acc_num=ucin1668618071106229

Abstract Details

2022, MS, University of Cincinnati, Medicine: Genetic Counseling.
Purpose Despite the large number of genetic tests available, their diagnostic yield, and their cost- effectiveness, not all patients have access to genetic tests. One barrier to genetic testing is insurance coverage, as out of pocket costs can be prohibitively expensive. Our current study reviewed and analyzed provider-insurance interactions about coverage of genetic testing in order to determine the frequency and outcomes of these interactions. Methods We retrospectively reviewed provider-insurance interactions for 322 patients at CCHMC from 2020-2021. We identified 356 genetic tests for which providers initiated preauthorization. Reported findings include preauthorization outcomes, appeals pursued, and factors associated with preauthorization approval. Results The majority of preauthorization requests were approved by insurance (77.5%). Patient insurance provider and type of genetic test ordered were associated with preauthorization approval (p<0.001, p<0.001). Of the tests that were denied by insurance, 52.4% were appealed. Overall, the appeals had a 60.6% success rate (20 preauthorization denials overturned by first or second round appeals). Conclusion The data suggests that preauthorizations are largely approved by private insurance companies, with type of genetic test and insurance provider associated with approval. When testing is denied by insurance, many providers choose not to pursue any form of appeal despite the high success rate of appeals. It is important to understand provider-insurance interactions so that more patients can have their genetic testing covered, thereby improving access to care.
Carrie Atzinger, M.S. C.G.C. (Committee Member)
Hua He, M.S (Committee Member)
Julianne Hartmann, MS (Committee Member)
Kathleen Collins, M.S (Committee Member)
31 p.
Genetics
insurance; preauthorization; prior-authorization; genetic testing; genetics

Recommended Citations

Citations

  • O'Sullivan, C. (2022). Frequency of Test Approval after Preauthorization, Peer-to-peer, Appeal Letter, and Independent External Review: A Retrospective Chart Review [Master's thesis, University of Cincinnati]. OhioLINK Electronic Theses and Dissertations Center. http://rave.ohiolink.edu/etdc/view?acc_num=ucin1668618071106229

    APA Style (7th edition)

  • O'Sullivan, Colleen. Frequency of Test Approval after Preauthorization, Peer-to-peer, Appeal Letter, and Independent External Review: A Retrospective Chart Review. 2022. University of Cincinnati, Master's thesis. OhioLINK Electronic Theses and Dissertations Center, http://rave.ohiolink.edu/etdc/view?acc_num=ucin1668618071106229.

    MLA Style (8th edition)

  • O'Sullivan, Colleen. "Frequency of Test Approval after Preauthorization, Peer-to-peer, Appeal Letter, and Independent External Review: A Retrospective Chart Review." Master's thesis, University of Cincinnati, 2022. http://rave.ohiolink.edu/etdc/view?acc_num=ucin1668618071106229

    Chicago Manual of Style (17th edition)

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This open access ETD is published by University of Cincinnati and OhioLINK.