Automating insurance approval: Real-world alignment of institution care pathways and payer policies.

600 Background: Prior authorization (PA) processes—intended to ensure appropriate, cost-effective care—often create significant administrative burdens and delay timely patient access to necessary care. This inefficiency stems largely from iterative communication needed to align payer policies with prescribed care plans. Guideline-based care pathways offer a potential solution. However, the real-world efficacy of integrated care pathways in improving PA outcomes across diverse payers has not been thoroughly assessed. We evaluated integrating radiation oncology pathways on PA efficiency, exploring their potential for a "gold-carding" system to automatic approval. Methods: As part of our institutional Smarter Radiation Oncology program, over 100 treatment directives (pathways) were developed, reflecting evidence-based national guidelines and best practices to help standardize care across a multisite academic radiation medicine department. These cover numerous disease sites and clinical scenarios, while unique situations allow for personalized off-pathway prescriptions. For this study, a pilot subset of directives (breast, prostate, lung cancer) was integrated into a commercial software system (InsightRT, Siris Medical, Division of TurningPoint Healthcare). The system tracked whether prescribed treatments adhered to these integrated directives (on- vs. off-pathway). Alignment with available written payer policies was also evaluated, and PA outcomes (initial approval/denial upon submission) were monitored. The statistical significance of differences in approval rates was determined using Fisher's exact test (p < 0.05). Results: Between 4/1/24 – 4/30/24, a total of 362 patient care plans with integrated directives were submitted to 27 different healthcare payers. 302 (83.4%) of cases used directive pathways. Prescribing on-pathway was significantly more likely to receive upfront PA approval (p = 0.037). On-pathway care plans achieved a 98.3% approval rate, compared to 93.3% for off-pathway plans. Consequently, on-pathway care plans were denied in only 1.67% of cases, whereas off-pathway cases were denied in 6.67% of cases—a 4-fold higher rate. Conclusions: Adherence to institutionally developed, guideline-based treatment directives led to significantly higher PA approval rates, confirming strong concordance with payer policies and national standards. These findings support pathway-driven care as a foundation for automatic authorization (“gold carding”) strategies, which can minimize administrative burden and care delays. Importantly, the high approval rate for off-pathway treatments also underscored the sound clinical judgment and overall quality of practice. Widespread implementation of care pathways has the potential to streamline PA, promote evidence-based care, and enhance timely patient access to critical treatment.