Date of Paper/Work

5-2023

Type of Paper/Work

Doctor of Nursing Practice Project

Degree Name

Doctor of Nursing Practice

Department

Nursing

First Advisor

Jocelyn Bessette Gorlin

Department/School

Doctor of Nursing Practice

Abstract

Deformational plagiocephaly (DP) is a condition in which an infant’s head becomes deformed and flattened because of molding forces that manipulate the malleable cranium. DP is very common, impacting an estimated 46% of infants within the United States. The resulting asymmetries of the head and face carry implications for functional, social, and emotional interactions. Helmet therapy is the recommended treatment for persistent moderate-to-severe plagiocephaly. It is most effective when started before six months of life with decreasing correction as the child nears one year old. Helmet therapy is very effective but is also expensive, and insurers have highly variable policies such as prior authorizations (PA) for reimbursement. The PA process is lengthy and requires substantial administrative and clinical effort from craniofacial advanced practice providers, including nurse practitioners and physician assistants. Insurers frequently require a peer-to-peer discussion, which is a conversation between the craniofacial provider and an insurer-designated medical provider to discuss reasoning behind the clinical recommendation. This is very time consuming and presents a significant administrative burden for the craniofacial provider. The process delays the initiation of helmet therapy, which may negatively impact patient outcomes. This quality improvement project, aimed at improving the prior authorization process, occurred over eight months within a mid-size pediatric orthotics group located in a large urban area in the Midwest. It included the creation and integration of a written brochure tool that was utilized in the PA process. Craniofacial providers and staff completed a pre-and-post-implementation survey assessing their perceptions of the tool’s impact. Additionally, data on insurer communications and outcomes were obtained before and after the tool’s implementation. Results indicate that the educational brochure (1) significantly improved response times from many insurers, thus improving access to helmet therapy for patients, (2) decreased the number of peer-to-peer requests, thereby decreasing the administrative load for the craniofacial provider and expediting access to therapy for patients and (3) ultimately was correlated with increased prior authorization approval. Although these results are limited by several variables, they demonstrate that proactive insurer outreach resulted in significant improvements in PA timeliness and administrative burden. For similar insurer-mediated delays, results suggest that it may be beneficial to facilitate proactive outreach to insurers.

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