Proactive Interventions for the Prior Authorization Process-Putting “Necessity” in Medical Necessity: How to Ensure You Are Maximizing Reimbursement

Video Transcription

Video Summary

This ACCC webinar focused on how oncology teams can better verify medical necessity to maximize reimbursement and reduce denials. Angie Santiago explained that medical necessity depends on payer rules, NCCN guidelines, Medicare national and local coverage determinations, and individual payer policies. She emphasized checking medical necessity before treatment is scheduled, documenting supporting evidence in the EMR, and attaching guidelines or authorization proof to help billing teams appeal or defend claims later. She gave examples showing how a treatment may meet NCCN criteria but still fail under a specific payer’s policy, and how some Medicare services require dual diagnoses to qualify.<br /><br />Sarah Shaw then described how St. Luke’s Cancer Institute uses Power BI to turn denial data into actionable trends. Their dashboard helps identify problem areas by control group, department, provider, payer, diagnosis, and procedure. By drilling into the data, the team can target training, improve workflows, and partner with other departments like billing, coding, and pharmacy. She shared examples where data-driven interventions reduced untimely appeal write-offs and improved documentation practices through retraining and better Epic smart phrases.<br /><br />During Q&A, both speakers stressed the value of ongoing training, provider buy-in, spot checks, and treating each order as a new review because payer policies and treatment guidelines change frequently. The overall message: strong documentation, continuous education, and data analytics are key to preventing denials and improving reimbursement.

Asset Caption

In the fifth webinar, we heard from Angie Santiago, CRCS, Manager of Oncology Financial Advocacy, Sidney Kimmel Cancer Center at the Thomas Jefferson University Health System, and Chair of ACCC’s Financial Advocacy Network, and Sarah Shaw, Oncology Program Manager at St. Luke’s Cancer Institute in Boise, ID. Our panelists discussed the importance of medical necessity in oncology and how clear denial data can help maximize reimbursement.

Angie Santiago, CRCS
Manager, Oncology Financial Advocacy
Sidney Kimmel Cancer Center
Angie Santiago, CRCS-I, is the Manager for Oncology Financial Advocacy, with the Thomas Jefferson University Health System, Sidney Kimmel Cancer Center. She created and implemented the Oncology Patient Assistance Program that is utilized at the Thomas Jefferson University Health System. The program was initiated to assist patients with the acquisition of supplemental financial coverage, over and beyond what has been traditionally provided by the hospital’s business office. Angie has worked in healthcare for almost 16 years within patient access, revenue cycle and financial counseling. She has presented on financial toxicity and related topics at patient navigators networking meetings. She is a graduate of the ACCC Financial Advocacy Network Boot Camp.

Sarah Shaw
Oncology Program Manager
St. Luke's Cancer Institute
Sarah Shaw is the Oncology Program Manager at St. Luke’s Cancer Institute. She is very experienced in financial advocacy for sensitive patient populations, insurance optimization, government and low-income subsidy programs, transplant financial coordination, and data collection and analysis. Recognized for being a strong patient advocate and liaison between patients and clinicians. Strong problem solver with the ability to analyze new processes and suggest process improvements. Adept at using a variety of documentation systems including Epic.

Keywords

medical necessity

oncology reimbursement

denials management

NCCN guidelines

payer policies

Medicare coverage

EMR documentation

Power BI analytics

appeal process

provider training