Utilization Management (UM) Policies and Procedures
An analysis has been conducted of the prior authorization policies and procedures at CDPHP. The report includes the entire Medicare population that had an authorization
in 2024. This population was then segmented into groups with social risk factors (SRFs) and those without social risk factors. A social risk factor, as defined by CMS, includes an enrollee with one or more of the following attributes:
The examination includes metrics dictated by CMS with calculations and comparisons for enrollees with specific SRFs and for enrollees without SRFs.
The results of the analysis found no statistically significant differences between the prior authorization outcomes of those with SRFs and those without SRFs. A slight variance was found in two of the measures associated with the percentage of prior authorization requests that were approved or denied. For approvals, the difference between enrollees with SRFs and enrollees without SRFs was 2.6 percent, with more enrollees without SRFs receiving approvals. For authorization denials, the difference between enrollees with SRFs and enrollees without SRFs was 2.5 percent, with more enrollees with SRFs receiving denials.
The total number of authorizations completed for those without SRFs totaled 14,175. The total number of authorizations completed for those with SRFs was 8,066.
It can be presumed that the slight contrast in approvals and denials for the two groupings is impacted in part by the total number of authorizations completed for each respective population. It is the determination of the UM committee that the prior authorization policies and procedures of CDPHP are not creating a source that is persisting disparities among enrollees with specified SRFs.
Health Equity Analysis
|
Enrollees with Social Risk Factors |
Enrollees without Social Risk Factors |
| Percentage of prior authorization requests for which the timeframe for review was extended, and the request was approved: |
100% |
100% |
| Average time that elapsed between the submission of a request and a determination, for standard prior authorizations: |
2.2 |
2.9 |
| Median time that elapsed between the submission of a request and a determination, for standard prior authorizations: |
1 |
1 |
| Average time that elapsed between the submission of a request and a decision for expedited prior authorizations: |
1.4 |
1.4 |
| Median time that elapsed between the submission of a request and a decision for expedited prior authorizations: |
1 |
1 |
| Percentage of standard prior authorization requests that were APPROVED: |
87.1% |
89.7% |
| Percentage of standard prior authorization requests that were DENIED: |
12.8% |
10.3% |
| Percentage of standard prior authorization requests that were APPROVED AFTER THE APPEAL: |
0.5% |
0.5% |
| Percentage of expedited prior authorization requests that were approved: |
88.8% |
89.6% |
| Percentage of expedited prior authorization requests that were denied: |
11.3% |
10.4% |