Aligning Prior Authorization Policies With Clinical Pathways in Oncology

Key Takeaways

• The Clinical Pathways Congress (CPC) 2026 included a panel of experts who discussed practical strategies for aligning oncology pathways with payer policies to reduce administrative burdens and promote patient care.
• Regarding prior authorization (PA), the panelists suggested using existing records to support alignment and providing reasons for treatment to promote approval and reduce the likelihood of denials.
• Proposed strategies included enhanced data exchange programs, designated clinical champions, and analysis of PA rejections.

At CPC 2026, panelists Linda Bosserman, MD, PhD, FASCO, FACP, David Jackman, MD, Gordon Kuntz, Olaf Lodbrok, MSc, MBA, and Terra Wonsettler, PharmD, MBA, examined practical strategies to align prior authorization (PA) with clinical pathways and reduce administrative burden and access barriers within oncology.

The session builds upon a previous CP Next conversation regarding PA barriers and challenges, with the panelists discussing organizational practices and strategies that might reduce repeated clinician reviews, improve direct communication between physicians and payers, and simplify approval processes.

Expert Weigh-Ins Regarding PA and Pathway Alignment

Dr Jackman described pathway-generated treatment summaries containing information such as disease characteristics, treatment lines, biomarkers, and dosing schedules. In this way, existing documentation could support PA procedures without repeating clinical assessments.

Dr Wonsettler explained how using the same data set when developing pathways and policies can promote alignment, with these decisions being based on disease states, biomarker testing, and treatment guidelines. She also emphasized the importance of patient-centered care, with therapies being influenced by individual comorbidities, tolerances, and preferences.

Dr Bosserman described her practice’s utilization of a large language model to extract payer-requested information from clinical notes. When making a case for coverage, providing the reason for a prescription as well as supporting evidence might accelerate approval.

Lodbrok estimated an 85% alignment between clinical pathways and payer policies, noting that separate payer portals still impede electronic exchange of pathway selections and supporting rationale.

Implications for Oncology Care

According to the panelists, priorities for oncology teams include recording clinical information once, documenting exceptions explicitly, and establishing reliable care contacts.

Strategies such as electronic data exchange pilots, designated clinical champions, pathway sharing, and analysis of PA rejections may help achieve the goal of reducing administrative burdens while maintaining patient-centered care.

Reference

Bosserman L, Jackman D, Kuntz G, Lodbrok O, Wonsettler T. Clearing the roadblock: solutions for prior authorization in clinical pathways. Presented at: Clinical Pathways Congress; November 10-11, 2026; Boston, MA.