Health Plans | Utilization Management Radiation Oncology

As the population ages, an increase of new cancer cases are expected to be diagnosed. 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. Unfortunately, many patients do not receive a treatment plan consistent with current medical evidence, primarily due to:

• Radiation treatment techniques without clinical evidence for specific cancer types.
• Use of more costly therapy without evidence of superior outcomes.
• Treatment fractions beyond what is necessary to achieve an equivalent result.

Established in 2009, our Radiation Oncology solution operates in all 50 states and supports Commercial, Medicare, and Medicaid members. Our solution reviews all cancer types and uses proprietary but publicly available clinical guidelines developed and continuously updated from peer-reviewed literature, professional societies such as NCCN® and the American Society of Radiation Oncology (ASTRO®), and nationally recognized academic- and community-based board-certified radiation oncologists.

By integrating the guidance of evidence-based medicine with the application of leading-edge technology, eviCore’s Radiation Oncology solution improves the quality, safety, efficiency, and delivery of cancer care.

eviCore’s Radiation Oncology solution ensures that patients receive the most appropriate treatment. Our solution is not designed to deny care, but rather to direct 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.

Our medical directors are all board-certified radiation oncologists with specific experience in the development and use of clinical guidelines in community and academic practice settings. In addition, we employ doctors of pharmacy, medical geneticists, pathologists, oncology nurses, and genetic counselors who contribute to holistic patient care.

Our Radiation Oncology solution is organized around each patient’s entire radiation course of therapy. Other vendor solutions may not consider the depth of information required to determine the most appropriate treatment regimen. Among other factors, eviCore’s evidence-based Radiation Oncology solution takes into account:

• Diagnosis
• Stage of disease
• Clinical presentation
• Histopathology
• Comorbidities
• Patient risk factors
• Performance status
• Previous treatment.

Our evidence-based clinical guidelines direct oncology physicians to the most appropriate treatment regimen, which may consist of one or more radiation treatment techniques. Once a regimen is selected, eviCore issues approval to the provider and seamlessly communicates the authorization to the health plan.

If the provider selects a treatment regimen not supported by eviCore clinical guidelines, eviCore prompts the provider to build a customized treatment regimen. To further support the request, the provider is asked to submit additional patient-specific information and scientific references. An eviCore board-certified radiation oncologist reviews the revised regimen request and may approve it as clinically appropriate based on the supporting information submitted. If the use of a customized regimen is not supportable based on all available information, the eviCore medical director will conduct 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.

eviCore’s Claims Studio is an integrated system with more than 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.

The success of the eviCore Radiation Oncology solution to promote evidence-based cancer treatment and reduce wasteful spending is repeatedly validated among local and national health plan clients around the country. Our solution results in a very low denial rate of <1% and increased compliance with evidence-based guidelines while reducing radiation therapy cost by as much as 20% compared to historical spend—without having to limit treatment options beyond evidence-based recommendations, or the patient’s choice of providers.

Our Radiation 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.

Medical knowledge doubles every 73 days. Our Radiation Oncology is a utilization management tool that helps providers quickly identify an evidence-based treatment plan based on each patient’s unique clinical situation and the most up-to-date evidence.

Our Radiation Oncology allows patients to have confidence that the tests and treatments they receive meet evidence-based standards. 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 and avoidable emergency room visits and hospitalizations)