Situation
As hospitals across the US continue to face rising drug costs, inconsistent reimbursement, and growing regulatory complexity, the need to optimize efficiencies across the entire care continuum has never been more dire. Leadership must work with their teams to dig below the surface of their hospitals to address the overlooked deficiencies costing them and their patients millions. This was the case for a two-hospital health system serving more than 140,000 people in the northeast. A particularly significant issue emerged in their oncology infusion services requiring an innovative solution.
Working closely with CompleteRx, pharmacy leadership discovered a fragmented chemotherapy prior authorization process leading to inaccurate, incomplete, and un-submitted prior authorization. Simultaneously, the process lacked centralization, registration workflows were inconsistent and, in some cases, absent, further compounding the issue.
Consequently, chemotherapy was often delivered without proper payer authorization, leading to denied claims and costly write-offs. In 2022 alone, more than $141,000 was written off across just 23 patients due to missing prior authorizations. These process gaps impacted hospital revenue, held up treatment, and, in a couple cases, left several patients with unexpected six-figure bills for lifesaving treatments — charges they neither anticipated nor could reasonably afford. This understandably led to confusion and concern, reinforcing the need for a more patient-centered, and payer-aligned approach.
Solution
Acknowledging the risks, the health system pharmacy director looked to CompleteRx, a long-standing strategic partner to create and launch a multi-dimensional strategy focused on process ownership, staff education, productivity optimization, and systemic safeguards.
Ownership & Oversight
Working closely with the pharmacy team, CompleteRx identified the need for a dedicated and centralized resource to own and lead the prior authorization process across oncology infusion services. In close collaboration with hospital leadership, CompleteRx helped establish the role of a Revenue Integrity Specialist within the pharmacy department. Funneling ownership to one department streamlined accountability maximizing cross-departmental alignment and the program’s success.
In-Depth Training & Centralized Support
Prior authorization is a complex and manual process with many required steps, a lack of standards and fluctuating rules. CompleteRx developed and delivered training for providers and nursing staff to reinforce best practices, proactive data collection, proper form completion and health plan requirements. This included customized training modules on the distinction between pharmacy vs. medical benefits and quick-reference tools to reduce dependence on manual research.
CompleteRx tracked the monthly write-off reports provided by the hospital’s Revenue Cycle department and maintained a proprietary denial tracking report to measure the effectiveness of these trainings.
In parallel, the CompleteRx team developed a centralized resource library on the health system intranet. This “one-stop shop” consolidated critical tools like J-code libraries, authorization grids, insurer portals and physician NPIs.
By streamlining these resources into a single, easily accessible hub, CompleteRx dramatically reduced the time staff spent searching for information, increasing accuracy and efficiency.
Systematized Workflow
A rolling weekly schedule enabled a proactive review of upcoming appointments. Custom tracker reports monitored regimens, payer plans, and authorization status, allowing the team to flag high-risk cases, identify trends, and act on issues in real time.
Checkpoints & Stopgaps
To prevent unauthorized chemotherapy administration, CompleteRx implemented multiple layers of review, including a final pharmacy check. This final checkpoint within the pharmacy system signified that prior authorization had been verified. If anything was missing, pharmacists were instructed to pause the process and trigger a review, ensuring no drug was mixed without reimbursement assurance.
Results
The results were immediate and impactful. CompleteRx helped recover $182,000 in lost revenue within the first six months. Average monthly write-offs dropped from $42,000 to $26,000, recovering approximately $16,000 a month in revenue. While it is acknowledged that not all write-offs can be avoided (due to billing delays or non-reimbursable supplies like tubing), the program has significantly reduced the volume and scale of unrecoverable losses.
Several additional KPIs, such as claim turnaround time, staff compliance rates, and denial prevention, were used to measure and gauge the initiative’s performance.
In addition to revenue gains, the program also provided critical secondary benefits, including a measurable decrease in chemotherapy drug waste and reduced inventory volume. These improvements have translated into further savings by lowering overall drug purchasing needs, another layer of operational efficiency achieved through stronger authorization and scheduling alignment.
Beyond the financial improvements, the initiative enhanced the patient experience by eliminating surprise billing. In one case, a patient faced nearly $250,000 in out-of-pocket charges due to a missed authorization, an error caught and corrected under the new system.
The program also refined the audit process to ensure reported write-offs reflected genuine authorization errors rather than unrelated issues, such as late billing or non-billable items like infusion tubing.
Conclusion
By partnering with CompleteRx and establishing a clear framework for accountability, this two-hospital system turned a critical challenge into a well-coordinated, high-performing process. The initiative now serves as a blueprint for revenue integrity in oncology infusion, with a projected ROI of 89%.
Hospital leaders credit the program’s success to proactive planning, operational discipline, and continuous collaboration between pharmacy, nursing, and revenue cycle teams.
For the foreseeable future, CompleteRx will work with the client to ensure program sustainability through ongoing staff training, insurance policy monitoring, and quarterly compliance reviews, cementing revenue protection and patient advocacy as standard practice.
