Guideline-Based Pathways Could Streamline Prior Authorization Processes
Key Takeaways:
- Prior authorization (PA) systems often create additional administrative burdens along with delays in patient care. Prescribing treatment according to a guideline-based pathway offers a way to streamline system approval.
- On-pathway plans—prescribed care plans or treatments that follow a pathway or directive—are more likely to receive automatic PA approval than off-pathway plans, or plans that were not prescribed according to a pathway or directive.
The main issues with PA procedures are that they can increase administrative burden and delay care access for patients. A study presented at the American Society of Clinical Oncology Quality Care Symposium aimed to streamline PA by using guideline-based care pathways to “gold card” automatic system approvals.
The Smarter Radiation Oncology program developed over 100 standardizing pathways based on evidence-based guidelines and best practices. The program implemented pathways related to breast, prostate, and lung cancer into a commercial system such as InsightRT, Siris Medical, or Division of TurningPoint Healthcare. The system assessed whether a prescribed treatment followed the uploaded pathway (on- vs off-pathway).
During April 2024, 362 care plans were submitted to any of the participating systems, 302 (83.4%) of which followed a guideline-based pathway.
On-pathway care plans had a higher approval rate than off-pathway care plans (98.3% vs 93.3%), meaning plans that followed a pathway were more likely to receive an automatic PA approval. On-pathway care plans only had 1.67% of plans denied as opposed to the 6.67% of off-pathway plans that were denied.
According to the study’s authors, “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.”
Reference
Chen WC, Carpenter C, Sidiqi BU, et al. Automating insurance approval: real-world alignment of institution care pathways and payer policies. JCO Oncol Pract. 2025;21(10):600. doi:10.1200/OP.2025.21.10_suppl.600
