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Health Plans | Utilization Management Radiation Oncology
Part of eviCore’s Comprehensive Oncology suite, our Radiation Oncology solution uses the most up-to-date evidence-based clinical guidelines from peer-reviewed literature, professional societies, and leading cancer physician experts to ensure that patients achieve optimal clinical and financial outcomes.
Our solution directs oncology physicians to the best treatment options for each patient, based on their unique diagnosis, medical history, pathology, prior therapy, functional status, and disease severity. We also ensure payment integrity by reviewing the appropriateness and accuracy of billed claims.
Challenges
The U.S. population is skewing older and cancer cases are on the rise. The number of patients undergoing active treatment for cancer has never been higher, the complexity of therapy options is proliferating, and patients are being treated for longer periods of time. Meanwhile, cancer treatment remains a heavy financial burden.
Unfortunately, many patients do not receive a treatment plan consistent with current medical evidence. We see requests for:
- Radiation treatment techniques without clinical evidence for specific cancer types
- More costly therapy without evidence of superior outcomes
- A greater number of treatment sessions than is necessary to achieve the best result
As well, the growing complexity of billing and coding guidelines for radiation oncology services leads to billing errors, resulting in incorrect payments and avoidable spending.
~90 million
adults aged 65+ in U.S. population
by 2050, vs. 46 million today1
Nearly 17 million
Americans are battling cancer today;
1.9 million new diagnoses in 20212
~50%
of cancer patients will receive
radiation treatment during their illness3
https://www.evicore.com/provider/clinical-guidelines
eviCore’s clinical worksheets, request forms, and guidelines are available online 24/7
Medical necessity review for radiation therapy requests for all cancerous and non-cancerous indications. Treatment techniques can include (but are not limited to) the following:
- 3-D conformal radiation therapy
- Intensity-modulated radiation therapy (IMRT)
- Stereotactic radiosurgery/stereotactic body radiation therapy (SRS/SBRT)
- Brachytherapy (low dose rate and high dose rate)
- Radiopharmaceuticals
- Proton beam therapy
- Post-service, pre-payment, claims review
eviCore’s has been managing radiation oncology since 2009. Our Radiation Oncology solution operates in all 50 states and supports millions of Commercial, Medicare, and Medicaid members. We partner with many national, regional and local health plans across the country.
Prior to joining eviCore healthcare, I had the privilege of spending over a decade caring for patients with cancer. During this time, I observed the field of oncology evolve rapidly with technological advancements that have helped prolong, and in many cases, cure cancer. However, clinical evidence does not always keep up with technology and sometimes the adoption of unproven forms of treatment can create financial toxicity for patients without a gain in clinical benefit. As such, it is critical to ensure that treatments and technologies are appropriately used for the right patient at the right time while being supported by published evidence and national guidelines. At eviCore healthcare, we put patient care first and, in collaboration with our clients, oncology societies, and physicians, we lay the foundation for positive patient outcomes.
