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Health Plans | Utilization Management

Medical Oncology

A pillar of our onConnectSM comprehensive oncology solution, Medical Oncology uses the most up-to-date evidence-based clinical guidelines from the National Comprehensive Cancer Network (NCCN®) to ensure patients achieve optimal clinical and financial outcomes. Our solution guides providers to NCCN-recommended treatment plans for each unique patient by using dynamic algorithms that minimize provider administrative time. By capturing only the clinically relevant information for each case, we present providers with clinical decision support and approval for a complete episode of care in as little as four minutes.

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Challenges

The number of patients undergoing active treatment for cancer has never been higher. The complexity of therapy options is multiplying and patients are being treated for longer periods of time. What’s more, as the population ages, we can expect an increase of new cancer diagnoses. 

Unfortunately, many medical oncology patients do not receive a treatment plan consistent with current medical evidence. The most common inconsistencies include:

  • Drug use beyond the recommended lines of therapy
  • Inappropriate drug combinations within a treatment regime
  • Genetic testing not performed when indicated
  • Administration of highly toxic drugs to patients with poor performance status
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Services Covered

Established in 2007, our Medical Oncology solution operates in all 50 states and supports Commercial, Medicare, and Medicaid members. We manage all cancer types, including rare cancers that NCCN® guidelines do not cover. 

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Overview

Our Medical Oncology solution uses clinical guidelines from the NCCN, a not-for-profit alliance of 28 leading U.S. cancer centers, to ensure each patient receives the correct treatment regimen. The foundation of our collaboration with the NCCN is our mutual dedication to improving and facilitating the quality, effectiveness, efficiency, and accessibility of cancer care so patients live better lives. 

For rare cancers not covered in the NCCN guidelines, our board-certified medical oncologists use up-to-date medical literature and the recommendations of medical specialty societies to ensure that all cancer patients receive evidence-based treatment plans.

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Clinical Expertise

Our medical directors are all board-certified medical oncologists and hematologists with experience in the development and use of clinical guidelines in community and academic practice settings. Our pharmacy specialists are doctors of pharmacy with residencies and experience in the development and use of evidence-based criteria and guidelines. In addition, we employ medical geneticists, pathologists, oncology nurses, and genetic counselors who contribute to holistic patient care and the maintenance of tested evidence-based clinical policies.

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Prior Authorization

Other market solutions process authorization requests for a single therapeutic agent. Typically, they don’t consider all clinically relevant patient information to determine the most appropriate treatment regimen(s), which often consist of a combination of therapeutic and supportive medicines. In contrast, our evidence-based medical oncology solution focuses on a patient’s entire drug treatment plan and guides oncology physicians to the most appropriate treatment regimen(s) using details that our clinical decision support application dynamically selects for each patient, including:

  • Diagnosis 
  • Stage of disease 
  • Clinical presentation 
  • Histopathology 
  • Comorbidities 
  • Patient risk factors 
  • Performance status 
  • Genetic or molecular alterations 
  • Previous treatment
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Appropriate Treatment Regimen

Once the provider selects an appropriate regimen, we issue approval to the provider and seamlessly communicate the medical benefit authorization to the health plan and the pharmacy authorization to the health plan’s pharmacy benefit manager.

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Deviations from Standard Practice Guidelines

If the provider selects a treatment regimen not supported by the NCCN® or our clinical guidelines, we prompt the provider to build a customized treatment regimen. To support the request, the provider is asked to submit additional pertinent patient-specific information and scientific references. One of our board-certified medical oncologists reviews the revised regimen request and may approve it as clinically appropriate based on the supporting information submitted. If the request is not supportable based on all available information, the medical director will perform a telephonic peer review with the ordering physician to collaboratively discuss the details of the case and ultimately determine whether a guidelines-supported regimen or a customized regimen is most appropriate before issuing a final decision.

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Payment Integrity

EviCore’s Claims Studio is an integrated system with over 85,000 proprietary and standard rules to accurately and consistently ensure that health plans and patients are responsible for only those healthcare claims that are authorized.

 

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Savings Opportunity

The success of the EviCore Medical Oncology solution to promote evidence-based cancer treatment and reduce drug costs was validated in a study published in the Journal of Oncology Practice (Oct 18, 2016), coauthored by Lee Newcomer, M.D., Senior Vice President of Oncology for UnitedHealthcare; Robert W.  Carlson, M.D., Chief Executive Officer of NCCN®; and Richard Weininger, M.D., Senior Strategic Advisor and former Chief Medical Officer of EviCore healthcare. This controlled, prospective study demonstrated that the EviCore Medical Oncology solution reduced denials from 7% to 1% and increased compliance with NCCN Guidelines® while reducing chemotherapy drug costs by 20% compared to the control group. The actual drug-cost savings were estimated to be $1.20 PMPM, without having to limit treatment options beyond the NCCN Guideline® recommendations or patient’s choice of providers.

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Payers

Our Medical Oncology solution optimizes the use of evidence-based clinical guidelines to deliver high-quality care to patients while avoiding the negative side effects and financial toxicity associated with unproven or less effective therapies.

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Providers

Medical knowledge doubles every 73 days. Our Medical Oncology solution is a clinical decision support (CDS) tool that helps providers quickly identify the most appropriate evidence-based treatment options based on each patient’s unique clinical situation and the most up-to-date evidence.

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Patients

Our Medical Oncology solution allows patients to have confidence that the tests and treatments they receive meet the standards established by the leading experts in their cancer type, drawn from the top cancer programs across the country. The solution offers the best chance for a positive outcome, and avoidance of the unnecessary costs and side effects associated with inappropriate health services (e.g., protracted therapy or avoidable emergency room visits and hospitalizations).

By integrating evidence-based medicine, outstanding clinical expertise and experience, and leading-edge technology, EviCore’s Medical Oncology solution improves the quality, safety, efficiency, and delivery of cancer care nationwide.

 

Frequently Asked Questions

Our integrated and proven Medical Oncology solution is a vital component of our comprehensive onConnectSM oncology management solution. Key components include:

  • NCCN® and eviCore evidence-based clinical guidelines for all cancer types
  • EviCore’s proprietary, regimen-based, and dynamic clinical decision support application designed for provider ease of use
  • Cost savings without the need to narrow regimens or the provider network
  • Inclusion of all therapeutic and supportive cancer drugs in one episode of care, including those covered under the pharmacy and medical benefits 
  • Electronic transmittal of approved HCPCS and NDC codes
  • Post-service, pre-payment claims review
Medical Oncology Insights
Clinical Expertise

“Prior to joining EviCore, I had the privilege of caring for the most inspiring group of patients imaginable as a pediatric oncologist. While I really miss spending time with those amazing kids every day, our healthcare system is badly broken. The administrative burdens that physicians face are very real and worsen every year. The opportunity to join an innovative team with real-world experience who are focused on trying to fix the system offered a chance to influence meaningful change that could benefit everyone. I am proud to work with such a highly dedicated group of experts who work toward that goal every day, while keeping our primary focus where it belongs—on the health needs of the patients we are honored to serve.” 

Dr. Eric Gratias
SVP & Chief Medical Officer, Oncology/Laboratory/Specialty Drug Services - SVP & Chief Medical Officer - Board-Certified Pediatric Oncologist

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