Prior Authorization: Where was that in Nursing School? (207-1)

5:00 pm – 5:30 pm Thursday, September 15
The world of healthcare has been dominated by discussion about COVID-19 over the past 2 years. At the same time, the field of pediatric hematology-oncology has continued to move forward with new therapies which offer hope for enhanced outcomes, specifically in the field of precision medicine. The topic that is not often recognized in those discussions is the growing complexity of payment for these therapies, as well as therapies that have been considered “standard” for many years. Nurses may be seeing increased requirement to participate in discussions about the cost or prior authorization of medications for their patients. In addition to these requirements, third party payors have growing expectations for prior authorization. At the same time, there are more third-party payor options on the market for families to choose, and unfortunately, some families are choosing plans that may not provide adequate coverage. The political climate has changed, as well, and the individual mandate for coverage, which was originally a part of the Affordable Care Act, was rescinded. New legislation has now created the No Surprises Act, which requires up-front estimate of the cost of care for specific situations. There was a time when care was scheduled as expected, and there was no need to worry about prior authorization, but in today’s world, nurses are likely hearing more and more about the status or need for “approval” of care in advance. This session will provide an overview of what pediatric hematology-oncology nurses may be experiencing as a part of daily operations in the care of these patients and families. An evolving model of multidisciplinary involvement to assure timely care in the face of growing third party payor expectations will be shared.