Fighting Insurance Barriers in Cancer Care with Ben Frank
Episode Summary
In this episode, David Raubach sits down with Ben Frank, a longtime colleague whose path into oncology began not in a boardroom or classroom but in a pediatric infusion suite in Columbia, South Carolina. At age 13, Ben was diagnosed with a rare blood disorder and spent months receiving treatment alongside children fighting cancer. That experience, watching their fear while he himself was not in mortal danger, planted a seed that would shape his entire career. He pursued a business undergraduate degree, then a Master of Health Administration at the Medical University of South Carolina, ultimately securing a coveted post-graduate fellowship at MD Anderson Cancer Center in Houston, a position he landed as the fourth-ranked candidate only after another candidate withdrew.
At MD Anderson, Ben’s fellowship introduced him to the proton therapy program, where he first encountered the insurance prior authorization process through work on letters of medical necessity. He credits Dr. Asha, a physician at MD Anderson’s Proton Center who had previously worked as a medical director for a payer, with instilling in him a “militaristic” approach to the appeals process, one that required understanding federal and state regulations precisely, tracking every 72-hour ERISA deadline, and writing individualized, research-backed appeal letters rather than boilerplate templates. After MD Anderson, Ben joined Provision Healthcare in Nashville as an early employee; a role that came about through a chance conversation at an ASTRO conference, where he eventually rose to president of the proton center and convinced Dr. Asha to join and overhaul the facility’s prior authorization program.
The episode’s core focus is the prior authorization battle that cancer patients and their providers face every day. Ben walks through the full appeal lifecycle: from the initial insurance submission and a common upfront denial, through peer-to-peer physician reviews, Level 1 and Level 2 internal appeals, to the critical endpoint of the Independent Review Organization (IRO), which places the decision outside the payer’s direct control. He explains that the most powerful tool in this process is not speed alone but the compounding effect of building a layered argument across each appeal level, weaving in clinical research (such as the Darby paper on cardiac dose), comparative treatment plans (proton vs. photon color-wash dose distributions), patient-specific anatomical factors, age considerations under the adolescent and young adult (AYA) framework, and socioeconomic variables like geographic proximity to alternative treatment sites. He also names “denial by delay” as a deliberate insurance tactic: knowing that cancer patients cannot wait indefinitely, payers slow-walk responses hoping the physician or patient will capitulate and accept a lesser modality.
Ben founded Apollo, initially with his business partner Chris Gonzalez, a dosimetrist, to commercialize this expertise and serve proton centers that lacked the internal resources to mount effective appeals. The Apollo-Unity arc is one of the episode’s most instructive storylines: starting in spare bedrooms with the Oklahoma Proton Center (David Raubach’s facility) as client number one, Apollo grew to serve a significant share of U.S. proton centers. They later built an internal digital platform to automate the process, eventually commercializing it as Unity. Ben describes Unity’s Version 2 appeal letter tool as producing letters that exceed the quality of what his team wrote manually, and he previews the near-future vision of a fully automated end-to-end prior authorization pipeline, including AI voice agents that negotiate with payers in real time. In the longer term, Ben envisions Unity becoming a neutral data intermediary between providers and payers, using accumulated approval-and-overturn data to eliminate prior authorization entirely for specific disease sites.
The conversation closes on the structural forces reshaping radiation oncology: bundled payment models that will replace per-fraction billing and incentivize hypofractionation; a forthcoming Medicare prior authorization pilot that Ben views with cautious concern; geographic access disparities (Oklahoma ranks between 48th and 50th in cancer mortality, partly due to rurality); the staffing shortages afflicting radiation therapists, medical physicists, and radiation oncologists; and the expanding role of proton therapy as capital costs fall and new technologies, including the Fit System, Leo Cancer Care’s upright delivery system, and Mevion’s compact cyclotron, lower the barrier to entry. Ben and David both express optimism about proton therapy’s trajectory while acknowledging that reimbursement instability, particularly a recent downward shift in MAC payment rates in Tennessee, remains an unsettling variable for the specialty.
What You’ll Learn in This Episode
- Prior Authorization Lifecycle: Insurance approvals for proton therapy move through an initial submission, peer-to-peer physician review, Level 1 appeal, Level 2 appeal, and finally an Independent Review Organization (IRO), with the IRO representing the only stage outside the payer’s direct control.
- Individualized Appeal Letters: Generic, one-page boilerplate templates fail; effective appeals incorporate disease-specific clinical research, comparative proton-vs.-photon dosimetric plans, patient anatomy, age (AYA framework for ages 19 to 45), and socioeconomic factors like distance to alternative facilities.
- ERISA 72-Hour Rule: Employer-sponsored health plans are federally governed by ERISA, which mandates a 72-hour response window at every appeal milestone for urgent cases. Submitting a written notice of violation the moment that deadline passes often triggers rapid payer reversal.
- Denial by Delay: Payers deliberately slow-walk appeal responses, sometimes extending the process 60 days or more, banking on the cancer patient’s urgency forcing them or their physician to downgrade to a lesser-covered treatment modality rather than wait for an overturn.
- Dosimetrist as Appeals Expert: Because dosimetrists design and optimize radiation treatment plans, they possess the deepest clinical knowledge of dose distribution and organ-at-risk avoidance, making them, once trained in insurance regulations, the most effective advocates in the appeals process.
- Comparative Dosimetric Plan: A color-wash comparison of a photon plan versus a proton plan, showing visually how dose is distributed across the body and heart, is one of the most persuasive documents an appeals team can attach, because even a non-specialist reviewer can see the cardiac dose difference.
- Unity Platform & AI Automation: Ben’s company Unity uses AI to automate the entire prior authorization workflow, including appeal letter generation. Version 2 of Unity’s appeal tool now produces letters of higher quality than manually written versions, and future builds include voice agents that negotiate directly with payer representatives.
- Payer AI Denials Risk: The United Healthcare controversy, using an AI platform to automatically deny high-cost claims without physician review, illustrates the danger of removing human clinical judgment from the utilization management process entirely, a trend Ben views as a serious threat to patient access.
- Bundled Payments & Hypofractionation: Radiation oncology is moving from per-fraction billing toward bundled payment codes for an entire treatment course, which will incentivize fewer, higher-dose fractions (hypofractionation), increase machine throughput, reduce administrative billing costs, and create pressure on facilities to optimize clinical efficiency.
- ASTRO Model Policy & State Legislation: Louisiana recently passed a law pegging commercial insurance medical policies to ASTRO’s model policy, which recognizes both Group 1 (strongly supported) and Group 2 (clinically registered) proton therapy indications; a legislative model Ben hopes other states will adopt.
- Medicare Prior Authorization Pilot: A new Medicare prior authorization pilot program is set to launch, introducing utilization management into a government payer that historically used coverage policies rather than case-by-case approvals, a development Ben calls concerning but watches cautiously for potential positive regulatory standardization effects.
- Employer Leverage on Payers: Large employers who self-fund health plans through TPAs are beginning to ask payers directly about denial rates on standard-of-care treatments, shifting the marketplace dynamic, because employees who are denied cancer care will hold their HR department accountable at benefits review time.
Ben Frank’s journey, from a teenager sitting beside pediatric cancer patients in a Columbia, South Carolina infusion suite to building AI-powered software that fights insurance denials at scale, is a testament to what happens when deep personal motivation meets rigorous operational discipline. His core message is that the prior authorization system, as broken as it is, has exploitable rules: ERISA timelines, independent review organizations, and the compounding power of a well-built appeal record can and do overturn denials at rates that most cancer practices never achieve simply because they don’t know the process. Unity represents the next evolution of that mission, removing the burden of that expertise from individual clinicians and embedding it into infrastructure that can serve every cancer patient who needs it. For patients navigating a denial today, for providers drowning in administrative burden, and for employers quietly selecting health plans that may be failing their workforce, this conversation is essential listening.
Full Transcript
Read Full Transcript
Transcript generated from the episode’s audio. Speaker names are identified from the context of the conversation rather than from recorded speaker data, and automatic transcription may misspell names and terminology. Please refer to the video for the authoritative version.
David Raubach: Thank you for joining us today on this episode of the Cancer Project podcast. I’m very happy to be joined by Ben Frank, a good friend of mine. He’s worked in oncology since 2014, started at MD Anderson Cancer Center, one of the top ranked cancer centers in the world. And we’ve had the privilege of working together in a number of areas, a number of locations. And today he is an expert on all things insurance related prior authorization as it pertains to accessing good cancer care. So, we’re going to talk about that along with just trends in oncology and cancer care going forward. Ben, very excited to be here. Yeah, thank you so much for joining us. So, I want to start at the beginning. So, 2014, you’re at MD Anderson. Why did you go into oncology at that point?
Ben Frank: Yeah, good question. So like many people was affected by cancer early on in my life. Different family members had it had to experience that as a young young child. But more importantly when I was about 13 I had a blood disorder pretty rare blood disorder and ended up spending about better half of a year better part of a year in an oncology practice pediatric oncology practice because the only oncologist or a hematologist in my community was also a pediatric oncologist and just got to experience you know what it was like sitting in a waiting room sitting in infusion suite with other kids that were going through cancer.
Ben Frank: I got to know a lot of those patients became friends with them and I just kind of sparked something in me then that I knew I wanted to go in oncology and that’s what drove me to pursuing a fellowship at MD Anderson and so that’s what I ended up doing.
David Raubach: So when you were doing the pediatric treatments where was that?
Ben Frank: So that was in Columbia, South Carolina.
David Raubach: Okay.
Ben Frank: Small little hospital there but basically my blood disorder was relatively benign compared to what those kids was going through. So, I had this weird experience where, you know, my life wasn’t in danger. I still had to go into this clinic on a weekly basis and sit there with them, but it was never as scary as it was for them. So, I got to see that from a different perspective by being a patient, but not being scared and got to almost see their fear and like talk to them through it as a teenager. And so it just had a lasting impact on my life.
David Raubach: Oh, I’m sure. And so then you did an undergrad in business.
Ben Frank: Undergrad in business and then I went to grad school for healthcare administration at the medical university of South Carolina. And one of the paths you can take when you’re an MHA is to do a fellowship which is a postgrad training at one of the big academic centers around the US. And MD Anderson is kind of one of the top locations to do a postgrad fellowship and it was also cancer focused. And so I really just honed my sights in there and honestly by just dumb luck I got accepted to it. I wasn’t even like the top candidate. One of the so that they picked three candidates every year to come into the fellowship program. I was ranked number four out of the cohort that interviewed and one of the people ended up backing out. So just through you know just luck I got in and so I think back on that a lot now
David Raubach: Just and so what was it like being at MD Anderson? It I mean one I’ve been there it’s an incredibly impressive c campus. And it’s also widely considered to be the top research cancer center in the country and really by many rankings the world. So it must have just been a really neat and even awe inspiring experience being on this campus with some of the top doctors.
Ben Frank: Yeah. Yeah. No, it is I mean you know when you work at Anderson you get to experience everything that an oncology center could experience over 10 years in like a one month timeline, right? So, they have the rarest, diagnoses that come there and they have the top doctors that work there and the best labs and the best imaging and everything you could imagine. And so, you know, it’s not realistic when you look at the community oncology setting to expect what you have at MD Anderson to exist everywhere, but I think we’re getting better at that. But when you do work there, it’s definitely all inspiring and it you kind of have to pinch yourself every day when you go into work.
David Raubach: What do you what did you learn there that maybe was different or eyeopening as opposed to your experience as a patient in a hematology setting?
Ben Frank: I think one of the first things I realized at MD Anderson that was I realized was going to be important throughout my career was the effect of a multi truly multi-disiplinary care when you have a surgeon and a rad onc and a med onc all working together and even radiology and pathology together on a patient. And when I was, you know, in Columbia, South Carolina as a patient just in hematology, obviously I didn’t have surgery and radiation oncology involved. I did have surgery later on. I had my spleen removed as part of my blood disorder, but those doctors never even really talk to each other.
David Raubach: Okay? You know, and it was just kind of like siloed in the community setting.
Ben Frank: And so when I went to MD Anderson, seeing that happen in real time and see sitting in grand rounds and these kind of peer-to-peer conversations happening about different patients was just like, “Oh, wow. This is a different way to deliver medicine and it makes a lot of sense. I understand why this is the top ranked cancer center.
David Raubach: Yeah, it makes a lot of sense. But now you start to see that in the community, you know. So, then when you were at MD Anderson, did you have exposure to their proton center while you were there?
Ben Frank: Yeah, actually that was the proton center was my first introduction to radiation oncology. So, when I was a fellow, the actual the preceptor for the fellowship that year was Tom Buckolds. He was the physician chief and he’s a radiation oncologist. So he did a really good job of connecting us in the radiation oncology division and a guy named Matt Palmer actually was kind of like our partner in the fellowship program that really just kind of like showed us around the proton center had us working on a project with him with letters of medical necessity first introduction to insurance issues and that is where my interest really just sparked. And then on top of that that year we had a fellow that was also a resident, a clinical resident, so a fourth fellow and his name was Nick Hillaker and he was a radiation oncology resident.
David Raubach: Okay.
Ben Frank: And so just got to learn a lot from him just by sitting like deskto desk learning about radiation oncology and really just kind of absorbing it.
David Raubach: So that’s interesting that you brought up insurance approval and prior authorization while you’re at MD Anderson because I would think if you’re MD Anderson and you say that a patient or a doctor says that a patient needs a particular treatment that’s just an automatic yes not that’s so even at MD Anderson they struggle [clears throat] with getting insurance approval.
Ben Frank: Yeah. General rule of thumb is the larger the health care system, the more leverage they have with payers and that generally the easier the process. But it’s not always a slam dunk and there’s always challenges. There’s always diagnosis that a doctor prescribes something for and the insurance company disagrees with it. And at the end of the day, the insurance company is the kind of arbiter of these decisions, at least on the financial side. They’ll like to say that it’s not a clinical decision, right? The doctor can still treat the patient with whatever modality they want, but there’s a financial cost to that and unfortunately these insurance companies are really standing in the way of that.
David Raubach: What were some things that you learned about the process at MD Anderson that you took away and wanted to apply in the community setting? What were things that you saw that they were doing well?
Ben Frank: Really breaking the process down in a militaristic format. I give a lot of credit to a doctor named Dr. Shaw. So he was a physician at the Proton Center that they hired. I believe he was at one of the payers before as a medical director. So he had this really deep knowledge on the process of prior authorization and utilization management. And he taught me actually later on at Provision when he came to work at Provision that you have to have a very defined process and you have to understand the regulations like the back of your hand. That comes down to federal regulations, state regulations, which differ by the way by payer, they differ by the type of plan it is. They differ by the location of the practice.
Ben Frank: And you know, if you what the way MD Anderson did it is just really understanding intricately every single case and following that process to a te and that always results in better outcomes, better approval rates, better overturn rates for denials. And so that’s one of the things that when you apply that in the community setting, you can replicate that success, you know.
David Raubach: So then from MD Anderson, you moved to Nashville.
Ben Frank: Yep.
David Raubach: So talk a little bit about that transition and how you ended up at the Proton Center there in Nashville.
Ben Frank: Yeah, that was a big move. So weirdly enough, you are the reason I’m in I was in Nashville. So
David Raubach: Okay.
Ben Frank: Yeah. My boss at MD Anderson at the time was sitting next to you, I think, at a conference somewhere, Robert Gafar.
David Raubach: Yes. Yes. Yes.
Ben Frank: And I he knew at that point that I was going to be moving to Nashville because my wife got a promotion to the corporate office for her company and so I called you and you said that you were building a proton center in Nashville with Provision and that’s how I ended up there. I was I think employee number one at that location.
David Raubach: Yeah. No, that was very fortuitous sitting next to Robert at a conference. I think it was the RaySearch users meeting in New York City I think is where I was talking to him. And for [snorts] those of you not familiar with RaySearch, they make a treatment planning software that we use in radiation oncology.
Ben Frank: Very good.
David Raubach: And so yeah, we were so I was at a company called Provision Healthcare and we had a proton center in Knoxville, Tennessee, and that center had opened in 2013 and I was the VP of operations for that center. And then that company made the decision to partner with at the time Tennessee Oncology and build a proton center in Nashville. There was no proton center at that time in Nashville. And so I moved over as the VP of business development to help get that project off the ground and get that center open. And then we knew we needed to hire somebody with a really strong operations background. And so yeah, we had that position open. And I think you started as the VP of operations.
Ben Frank: Yeah, something like that. Or director of operations, something like that. Yeah.
David Raubach: And we had because we had Jim Gray as the medical director. So he was the radiation oncologist kind of running things from a clinical throughput and clinical process standpoint. And then everything on the business side we turned over to you. Y and we crossed path crossed paths briefly because that was about the same time that I left to go work on purchasing the Proton Center in Oklahoma City, the Oklahoma Proton Center.
David Raubach: So what was it like? I mean because you know you were in fellowship at MD Anderson. I think you maybe worked there for a little bit afterwards and then now [snorts] you you’ve got this facility that you’re in charge of. Oh man. What was that like?
Ben Frank: It was a big move. Basically going from having a very siloed job at MD Anderson. I think when I left MD Anderson, I was over the capital purchasing and planning for the division of Rad Onc to basically being over everything for an entire practice. It was a big shift and honestly the biggest shift was just culturally startup mentality is very different than academic operations and so you know moving into a startup mode proton center you know it was just all hands- on deck all the time lots of work lots of time lots of energy and honestly it was a lot of fun.
Ben Frank: Yeah, I think you know that was I look back on that and I like to say I learned a lot at MD Anderson, but I learned more about business working at Provision and learned more about the business of oncology, the business of radiation oncology more specifically and how to scale that. And what the kind of like knobs are that you turn on making this a practice successful like going out and recruiting, you know, physician referrals or developing those relationships, going out and finding the right clinical staff because, you know, you’re not MD Anderson. People don’t just want to come work for you all the time, so you have to go do leg work and recruiting people. And so, you know, I think it was a it was definitely a culture shock at first, but I look back on it fondly, like it was a really good time for me.
Ben Frank: And honestly, it springboarded me into my first company, learning, you know, startups.
David Raubach: So, and I you bring up a good point about the staffing because that’s an overwhelm. It you know, it’s one thing to say, okay, well, we have one open position. We have to hire a radiation therapist. We have to hire a nurse. They’re going to we’re going to bring them in. We have processes already established. There’s a culture already established. But when you’re hiring everybody all at once, that is overwhelming.
Ben Frank: Yeah. And you know, it I remember because I’ve been a part of helping open four proton centers and you’re right, there’s a lot of enthusiasm and energy. There’s a lot that can go wrong. You’re having to make quick decisions on the fly. Some things are going to work great, some things are not. You also kind of have to go into it with a mindset of not everybody that you hire is going to be here six six months from now because there’s people that are going to come in and think this is where they want to be and then they decide it’s not where they want to be and so you have to navigate those challenges.
David Raubach: Y you also got the first opportunity to take what you learned about the insurance process and getting insurance approvals and apply that at Provision. What was your mindset going into that and what are some things that you think worked really well and some things that maybe needed to be improved on over time?
Ben Frank: Yeah, so when we started the proton center in Nashville, we actually took the model that was being used at the Knoxville Proton Center and applied it which wasn’t a bad process. They had a really good success rate but you know over through some conversations and some convincing I convinced Shaw from the proton center at MD Anderson to move up to Nashville to help run the proton center and it and really reshape the way that we approach prior and so that’s where I really learned like okay this is this goes a lot deeper than what we’re doing right now and there’s a lot of opportunity to start overturning these cases but I think in the private practice world compared to MD Anderson you don’t have that leverage that they typically did with the payers. So, you’re almost starting, you know, behind the eightball a little bit.
Ben Frank: And but, you know, nonetheless, we were still successful. We still achieved the same overturn rates that, you know, some of the most successful proton centers are getting at our, you know, little private proton center in Nashville that didn’t have any leverage and didn’t have a lot of influence. And so, it proved to me then I was like, “Okay, there’s something to this.” like this this is something every proton center needs to have access to.
David Raubach: So, for those of listeners maybe that haven’t gone through something like getting treated for cancer and having to get insurance approval, go through the steps that a patient is experiencing along the way and then maybe that what you were doing on the back end to try to get that approval and maybe specifically in a situation where there’s an upfront denial. So, what does that process look like?
Ben Frank: Yeah. So when you go into a consultation with your physician and they decide that they want to treat you with protons, the next step after that is getting authorization approval from the insurance company to actually treat you with the prescription or the modality that the doctor has prescribed for you. And you know that process can be simple. It can take three days. It could be hey insurance company we’d like to treat this person with protons. And they say yep you’re good to go. And that would be a covered indication.
David Raubach: Okay.
Ben Frank: When it’s not a covered indication, take breast cancer for example in proton therapy, then they’ll deny it and a lot unfortunately a lot of physicians around the US and a lot of practices around the US when they get that denial they just go back to the patient and say I’m sorry you were denied. You have two options. We can downgrade the modality to IMRT or 3D or whatever it may be or you can pay out of pocket. And that’s that can be devastating for a cancer patient. And that is one of the biggest things that motivates me is I hate that conversation.
David Raubach: Yeah.
Ben Frank: And I’ve had to have that conversation as someone who ran a proton center. And so when you can go back to that patient and say, “Hey, you got denied, but we also have this federally regulated process or state regulated process where we can appeal that denial and we have multiple levels that we can appeal it.” Ultimately getting outside of the insurance company, then it changes the mindset of the patient, say there’s still an opportunity here. And so what that process looks like is once we get the denial, we either have a peer-to-peer where the physician talks to their physician and those they’re kind of hit or miss on whether or not you can be successful with them depending on the physician
David Raubach: Yeah. That’s on the phone.
Ben Frank: But the biggest step after that would be writing an appeal letter.
David Raubach: Okay.
Ben Frank: And these appeal letters can be short. If you go to a typical practice around the US, they’re probably using templates that are one page long saying, “Hey, I want to treat with this modality.” Not really giving any context why. In our scenario, what we were doing and what was being successful is we were writing very long detailed letters on why this should be approved using research, using clinical justification, even like social factors with the patients individual case on why they should be treated with any certain modality. And that appeal structure is what ultimately leads to the success. And so I mentioned there’s three levels. So you have appeal level one, appeal level two, and IRO. And the ultimate success metric in my opinion is getting to IRO, which is independent review organization.
David Raubach: Okay? And so what that means is that it’s out of the payer’s hands. Okay?
Ben Frank: And this really applies to certain commercial medical policies or insurance policies. But when you get to external review, you’re supposed to be talking to someone who’s non-biased, right? That is look looking at all the facts on the table, the clinical case, the medical policy, whatever may be relevant, and they’re making a decision on whether or not that should be covered under this insurance plan. And what we found is that if you build a story of appeal arguments over time over that level one, level two, and then getting to external review, then the success rate at external review just goes up significantly, right? It pay it pays dividends to invest that time through the appeal process. And so that’s where really the success of our program came from it and that’s what Dr. Shaw taught me is like this is why you have to have a militaristic approach to this process.
Ben Frank: And so that’s you know it’s it sounds like a lot of work and it is but it is very takes time resources.
David Raubach: Yeah. So maybe let’s use the breast cancer case as an example. So let’s say it’s a left-sided breast cancer. We’re treating an area. We’re treating the chest wall. Maybe it’s after a mastectomy. There’s lymph nodes involved. So, that’s a big area that’s getting radiation and it’s a big area getting radiation in close proximity to the heart and potentially other critical structures like the lungs or esophagus. So, that’s a case that maybe for whatever reason the insurance company doesn’t have that on their coverage policy, meaning they’re not going to approve every single leftsided breast cancer case. You’re not going to get that upfront approval.
Ben Frank: That’s right.
David Raubach: But the doctor says proton therapy is a better option for a variety of reasons, whatever it may be. What is going into when you talk about the detail, what’s going into those appeals letters and those conversations with the doctors for that particular case.
Ben Frank: Yeah. So for a leftsided breast case, yeah, we would bring in specific research related to dose to heart.
David Raubach: Okay.
Ben Frank: So when you’re do using photons sometimes the distribution of radiation to the organs at risk or what we call OARs can be significant enough that proton therapy is justified. Meaning if we can use a different modality to avoid delivering radiation to the heart which is near the left breast then that is a good thing for the patient. And so the way we do that is we bring in research to show that hey there’s been historical analysis done on multiple cases that show that we can reduce heart dose using proton therapy compared to photons. We’ll also create a comparative plan. So during the radiation therapy process there’s a treatment plan that’s created by dosimetrist. In proton therapy a lot of times we’ll create two plans. We’ll create a photon plan.
Ben Frank: So an IMRT or 3D or VMAT and then we’ll create a proton plan and we’ll compare the two to see okay what is the dose being delivered to the heart in the photon plan? What is the dose for the proton plan? What is that delta? Is it significant? And then we compare that delta and those numbers to what’s called QUANTEC dose limits, which is a kind of gold standard library of organs at risk and the kind of dose that you can deliver to that organ without causing significant damage and we’ll use that independent data to justify the modality.
David Raubach: And the heart is very sensitive to radiation.
Ben Frank: Correct.
David Raubach: We know that.
Ben Frank: Yeah. Absolutely.
David Raubach: Also from clinical research.
Ben Frank: Exactly. So there’s a really famous study called the Darby paper basically shows that there’s a significant increase of cardiac event, you know, based on the amount of dose that you receive to your heart.
David Raubach: So you’ve got this comparative treatment plan where you’re actually taking the time or this this is the facility or their dosimetrists are taking the time to put together both a proton plan and a traditional radiation or photon plan and comparing the dose difference. And I guess there’s a print out of images with those calculations.
Ben Frank: It’s pretty it’s called a color wash. Basically shows the beams and how the radiation is being distributed across the body. So we put that together for the insurance company to review and also the external review organization. And basically it shows them like okay clearly in the photon image we’re having there’s you can see the heart on the image and you can see dose going through it. On the proton plan you can see this great conformal distribution of dose and the hearts being completely avoided altogether. Sometimes that is enough to justify getting an approval. Sometimes it’s not because there’s an argument that some dose to the heart is okay and that’s actually true. But in some circumstances depending on patients anatomy depending on prior radiation it could be completely you know it could be a very bad situation for the patient to treat them with photons.
David Raubach: So you mentioned also being patient specific.
Ben Frank: Yes.
David Raubach: What do you mean by that? The individual appeal letters.
Ben Frank: Yeah. So every patient’s case is different. Their anatomy is different. Their specific diagnosis could be different. Their plan is different. Their health plan. And so you can’t just use a template to say, “Hey, I want to treat, you know, this left breast case with protons and use the same boilerplate language for every single case and expect insurance companies to overturn those denials.” They want to see real justification on why this specific patient needs protons. Why is why give me the reason to overturn this case is the way that we kind of see it from our side. And the only way to do that is to dive deep into that patient’s case, understand why they need protons, understand dosimetrically why they need protons, but also from a socioeconomic perspective, you know, they might not be anywhere near a photon practice. We’ve used those arguments in our appeal letters as well.
Ben Frank: And so, you know, there’s there’s a lot of different variables. Another one is age. So, protons, being able to avoid organs at risk and delivering a, you know, less dose to those organs. If you are a younger patient, you obviously have a longer life to live, definitive course of treatment, obviously. And what that means is that the second the late effects of the radiation exposure will not be experienced by someone who’s older, but in a younger person, you may experience those, right, those effects. And so we use arguments for AYA, so adolescent young adult all the time. And it’s very successful. So if you’re, you know, between the ages of 29 to 45, that’s kind of that AYA area. And then, you know, getting outside of that, excuse me, it’s I think it’s 19 to 45.
David Raubach: Okay.
Ben Frank: But yeah, so like if you fall within that group, like I would say that you definitely need to be considering protons.
David Raubach: Yeah.
Ben Frank: But you know, there’s there’s a ton of different variables and being specific about them is the most important part.
David Raubach: I think one of the things too that I’ve noticed reading some of the appeals letters that you guys have written is that you understand that it’s not always a radiation oncologist that’s reviewing all of the information, right? So, yeah, preferably it would be because a radiation oncologist would be the one that would understand all of these nuances that you’re talking about. And so I think you guys always did a good job of saying this may be a primary care physician or a rheumatologist or a surgeon or somebody who’s not necessarily familiar with practicing in the field of radiation oncology.
Ben Frank: So we almost have to write it a little bit in layman’s terms or explain things in a way that somebody who’s not familiar with radiation oncology could understand.
David Raubach: Yeah.
Ben Frank: Yeah. And unfortunately that happens not as much as it used to. But you know when we started in this process it was not uncommon to be arguing against an ER doctor for a radiation oncology case that had never obviously never treated with radiation for any of their patients but had very little insight on what proton therapy was or what the difference between protons and photons were. So, you know, it can be extremely frustrating and there’s a lot of different variables on the payer side and barriers that are put up that are specifically in my opinion that are designed to dissuade people from pursuing appeals and make it harder, make it a more cumbersome process, make it bureaucratic. And so, you know, what we did in my first company, Apollo, was we really just took that head-on and we said, “Hey, we’re going to be the antithesis of whatever they’re doing.”
David Raubach: Yeah.
Ben Frank: We’re going to fight fire with fire.
David Raubach: Yeah. And that’s So, talk a little bit about that because you were at Provision and eventually became the president of the Proton Center there in Nashville, but then really felt like there was an opportunity and a need. Which is why anybody should start a company. There’s an a need and also a financial opportunity. So you left and started and actually I want to step back here because we had a conversation in Chicago. I remember that we were on a at a rooftop bar.
Ben Frank: Y at ASTRO.
David Raubach: So this is the big radiation oncology conference and you told me that I had already left to go to Oklahoma and you told me that you had this idea. Y and I said go for it. That was the start.
Ben Frank: Why not? That was the start. Yeah. So that conversation kind of validated the concept. I remember asking you I was like hey if this service existed and this is what we could achieve would is that something that you as an operator of a proton center would want to engage with and you were like yeah of course and so why wouldn’t we want to get more cases approved for proton therapy so that was the start of it and you know shortly thereafter I you know my time at provision was coming to an end and kind of like learned as much as I thought I could learn there and I knew honestly because of being in that environment I was like I there’s an entrepreneur reneurial spirit inside of me that I wanted to just go out and explore and so I left to start Apollo with my partner now Chris Gonzalez and so he and I just kind of started in our spare bedrooms you know working on proton cases.
Ben Frank: You guys were [snorts] client number one and you know it just started with an idea and we really just adapted it over the next few years and took over pretty good portion of the proton centers in the United States.
David Raubach: So I think as you brought up Chris I think that was an interesting partnership because you had the business side running a proton center mha fellowship at MD Anderson but he was a dosimetrist.
Ben Frank: Yeah.
David Raubach: So good point.
Ben Frank: Yeah.
David Raubach: So why did you partner with a dosimetrist for this particular endeavor?
Ben Frank: So yeah getting back to so Dr. Shaw specifically when he was teaching us about prior authorization, one of the key variables on successful prior is having someone who intricately knows the clinical side of the argument. And in our world, dosimetrists are the best kind of clinicians to take that argument on because they’re the ones making the plans. They know the dosimetry very very well. The best way, you know, for the patients out there and people watching this, the best way to understand a dosimetrist is to really think of them as the pharmacist for radiation. So they have this really deep intricate knowledge of the science and the modality that they’re delivering. And so if you can teach those people prior authorization and appeals then they’re really unstoppable. It’s you know kind of best of all worlds. And so Chris was trained in this process and knew it really really well.
Ben Frank: And so we kind of married together as just like this perfect partnership to grow Apollo.
David Raubach: Yeah. So you had this person that was familiar with actually making treatment plans. And I think this is important too. The dosimetrist is often the one that is helping to decide what type of radiation is the best way to deliver the treatment to the patient. Meaning that they’re the ones that are saying this is the absolute best that I could do with an IMRT plan.
Ben Frank: Yep.
David Raubach: This is the absolute best I could do with a tomotherapy or a VMAT plan. Different ways to deliver radiation with photons. This is the absolute best I can do with a proton plan. [snorts] and they’re going to be able to speak as an expert on the ability to deliver radiation in the safest and most effective way possible. So you have this person. So then you it was really just a matter of teaching this person how to write letters to insurance companies and followup process.
Ben Frank: Yep. And you know I can’t take credit for that because it’s not something I did. It’s you know something that Chris learned through his experience at MD Anderson and through Dr. Shaw. You know they they really like they spend a lot of time learning that process outside of dosimetry but just understanding the insurance process which is a specialty in and of itself. But yeah you’re right like dosimetrists their skill set is really just optimizing plans. It’s optimizing the prescription that the doctor writes. Once the doctor writes the prescription they’re drawing their targets saying hey this is where I want you know delivery to happen. And then dosimetrist’s job is to optimize delivery to that while avoiding as much healthy tissue as possible. And so they just get this really deep intricate knowledge of like every single case.
Ben Frank: And if you take those people and apply it to the insurance process, who better to argue on behalf of the patient than the person that knows it the best, you know? And so that’s where it all started. And it ended up being very successful. And I would advocate for that in every specialty, every every healthcare specialty. You should have highly knowledgeable clinical people doing these appeal arguments.
David Raubach: Yep.
Ben Frank: And I’m an administrator, you know, that’s my background. And I not to sell administrators short, but clinicians are the best people to do this job, unfortunately. And it’s a bureaucratic process. And in my opinion, it shouldn’t exist, but it does exist. That’s the reality. And if you want the best chance of getting those cases overturned, people that know the clinical details the best are the ones that are going to have the best outcomes.
David Raubach: I think there’s to me there’s like three pillars with this approval process for a patient. There’s understanding the patient the details of the patient’s plan and a lot of times practices or facilities will have financial counselors or financial coordinators that part of what their job is to look at the patient’s plan and say what are your in network benefits out of network benefits? Is radiation covered as part of your plan? Who do we what’s the phone number that we’re supposed to call? Is this an ERISA plan? Is it a state plan? Etc. So is it a self-funded plan? And so you have this these financial counselors that are liaisoning or communicating with the patient about the nuances of their particular insurance plan.
Ben Frank: Yeah.
David Raubach: Then you have the [snorts] person and it could be the financial counselor, it could be the administrator like you, it could be the dosimetrist, but somebody needs to understand the regulatory process.
Ben Frank: Okay.
David Raubach: Well, now we know what the plan is. Well, what’s the what’s what are all the rules about the approval process that apply to that particular plan? And then there’s the clinical aspect.
Ben Frank: Yep.
David Raubach: And so those three things have to work in concert. And if you could put them all together, that’s the holy grail. And that’s what you guys did well.
Ben Frank: Yeah. Exactly.
David Raubach: So talk a little bit about some of the quirks or intricacies of the regulatory process like what are some things that you guys always had to keep in mind whether it was from a what the paperwork looked like or the timing of filing appeals. Talk a little bit about the biggest thing in from a regul
Ben Frank: So when it comes to regulations the biggest rule that people out there that are looking at prior authorization and patients that are having to undergo it is ERISA so if you have a employer sponsored health plan there are federally regulated processes for prior authorization for any employer sponsored health plan and those and that’s a big chunk of American healthcare I think it’s 60% or so of commercial plans That process in and of itself when we started this we realized that plans rarely followed the rules okay with ERISA and it was because no one was you know overseeing them no one was calling them out on it and so what we did on our side is we said hey these ERISA laws are pretty specific so for example if you have an urgent case which we believe you know most cancer diagnoses are urgent so let’s submit them urgently you have 72 hours from every milestone every every one of those appeal steps you have 72 hours to return decision to us health plan.
Ben Frank: And what we were noticing is that they weren’t responding in 72 hours. It might take them a week or more. But what we learned is that if you submit a denial on that 72-hour mark or an appeal letter, excuse me, on that 72-hour mark, even before you get the denial, and to say, “Hey, we notice it’s been 72 hours. We’re going to assume that you’re denying this, but you violated the ERISA law. Here’s the specific law that you violated.” Right? A lot of times they’ll reach back out to you pretty quickly and say, “Oh, this is now approved.”
David Raubach: Right. Right. Right. Because the worst thing that can happen for an insurance company is to break the law, right? Like that creates a lot of liability for them. Right. And I mean, you guys would literally write the rule or the law into the letter.
Ben Frank: Yeah. We’d make sure that all the relevant information was in the letter, whether that be the law, clinical research, even specific health plan clauses. So employer sponsored health plans can have unique processes in and of themselves that are even more strict than what ERISA governs. So the so let’s say you know make up a company XYZ that has a self-funded insurance policy and they’re in Oklahoma. They can say you know what I want my insurance I want my prior authorizations I want you to have a response back to my employees sooner than 72 hours. They should have 24 hours.
Ben Frank: And so there’s specific cases like that where you know you have to know those things really really well and it’s important to get your SPDs which is a standard document that every employer gives their employees that outlines all of these things for their benefits and then also looking at the health plan policy looking at the medical policy. There’s all sorts of rules that you just have to like be really aware of when you’re going into this process. And over time if you have the same people doing it then they get they remember these things. So like the bigger employers and the bigger health plans, they just know. And then they have direct lines that, you know, hey, I’m going to call this medical reviewer for this case because, you know, this is something I’ve talked to them about before in the past.
Ben Frank: And so you start learning those things, get a little tips and tricks here along the way. But yeah, I mean, timing is the biggest thing that helps us.
David Raubach: Well, and I think in taking advantage of like what you talked about that this really is an urgent case and there’s rules about responding in a timely manner because one of the tactics that we’ve noticed that insurance [snorts] companies will use is denial by delay.
Ben Frank: Yep.
David Raubach: So, tell me what that means in your world, denial by delay.
Ben Frank: So, prior authorization denials in the appeal process could easily extend out to 60 days, maybe even more. Just simply from the insurance company not responding to your appeal letter. And what that means is that they’re hoping that the physi the case is so urgent. So, it’s cancer obviously, so you have to get the patient on treatment ideally as soon as possible, unless they’re in watchful waiting or something like that. That the physician will become so agitated and the patient will become so agitated that they’ll just they’ll compromise and say you know what I’ll just take a le lesser modality right you know and that is denial by delay so we don’t want that to happen we want whatever the physician has prescribed to be delivered to the patient because that is the best course of action but the insurance company you know they know that if they delay things long enough that you won’t have a choice you’ll have to take a lesser modality and then the insurance company can say well no we never denied the case the patient chose to They made a decision on our own.
Ben Frank: I think that’s onethird of all denials.
David Raubach: And so how do you combat that?
Ben Frank: Speed.
David Raubach: Okay.
Ben Frank: So it’s holding them accountable to those timelines and then matching the speed. So if ERISA says every 72 hours, your timelines have to be faster than 72 hours. Okay? So you have to get those appeal letters out the door. And it’s a lot of work to cram into a short timeline. But what we’ve noticed is that at first the insurance companies are typically like taking it back by our speed. Mhm. And the depth of our appeal letters, but over time they start matching our speed because they know that we’re not going to let them sleep on it. Yeah. And so that is the biggest factor when doing priorization is having a process laid out and then following that timeline to a tea and do not let it slip because you will have patients that fall through the cracks.
Ben Frank: You’ll have patients that get too agitated and stressed out and they’ll rightfully so they’ll want to go either to another clinic or they’ll downgrade their treatment. And then same thing with providers. You know, providers hate prior authorization. It’s like I want to say it’s like 99% or 98% of providers say that prior authorization is like their biggest headache. Yeah. But yeah, it’s you just have to have a really good process and follow those timelines because they will match your timing over time.
David Raubach: So, you’ve spent a lot of time [snorts] as you’re navigating this process communicating with patients and it’s a high stress situation. Patient has [clears throat] cancer. They’re potentially facing big medical bills. They don’t know if the treatment that their doctor is recommending for them is actually going to get approved. And so, and just to put this in perspective, a course of proton therapy may cost 40, 50, $60,000. It might cost $100,000. It’s a lot [clears throat] of money.
Ben Frank: Yeah.
David Raubach: What are your conversations like with patients? What are you telling them to just help ease their burden a little bit going through the process?
Ben Frank: Use a lot of data now because we have data to that helps us understand what their likelihood of getting this overturned is. We did a good job in the early days of Apollo collecting all of that. Now with Unity, we have a digital platform that we can actually show patients like, hey, this is your likelihood of getting approval. But also staying in communication with those patients at every step along the way because what happens typically in a community setting is that there’s usually one person working on prior authorization and they are completely overworked and overwhelmed and they don’t have time to call every patient with every single update because they’re in the community setting. They’re trying to wear multiple hats and there’s just a lot of workload.
Ben Frank: But with Apollo, what we did, we made it a priority is we’re going to let every patient know every 72 hours what’s going on with their case. And we’re going to make sure that they know all the details, the good and the bad. And that gives them enough information so that they can have relevant conversations with their physicians. Oh, and by the way, the physicians are also getting updates from us as well, so they are constantly in the know on what’s going on. But I think that’s really the only way that you can that plus the data is the only way that you can really ease those stressors. But it’s a lot better than not knowing anything because in the community setting, you might not hear anything, right? For a month and when you have cancer, a month goes by, you haven’t heard anything. I mean, just imagine the stress.
Ben Frank: It’s it would be absolutely terrible situations.
David Raubach: Yeah. That and what you just described that transparency and that regular communication that applies on the clinical side, but it also applies on the financial side. There’s this like financial diagnosis that comes along with the clinical diagnosis and you want updates on the status of the financial situation and you guys did such a good job of staying in touch with patients and communicating with patients and being very transparent. What how have you seen so shifting gears a little bit AI is a hot topic right now. So, how have you seen AI impact this whole process?
David Raubach: Maybe both on the positive side, you talked a little bit about data collection on your end of trying to get approvals, but maybe on the negative side as well where you there’s there was a big case recently with United Healthcare where they got in some trouble for using creating an AI platform that was automatically denying. There wasn’t even a person looking at these high-profile cases. It was a software program that was making the denial. So talk a little bit about the impact that AI is having.
Ben Frank: Yeah. So I I’ll back up a little bit and talk about in the early days of Apollo we knew early on that we had to have a digital platform to scale the service and so we started building something for ourselves internally and we called it I think at the time we just called it the Apollo platform or something something really generic. But we started building this system and over time we started implementing automations into it because to scale a solution where that’s completely driven by clinicians is really hard and it’s just not something that’s obtainable for most cancer practices around the US. They can’t afford to hire a full-time dosimetrist to do prior authorizations. It just doesn’t make sense.
Ben Frank: So we knew like okay we have to take as much of the knowledge out of our heads and put it into a tool that can automate these steps as much as possible. And over time, our customers started seeing this system on grand rounds and other meetings and they’re like, “Hey, what’s that thing?” Yeah, I want to use that. Yeah. And so that’s we commercialized Unity a couple years ago and we changed the name obviously. It’s called Unity now. But it’s really leveraging AI to automate this process. And our vision for Unity is that in the future, not so distant future actually, this entire process, including appeals and all of those timelines that I’m talking about, will happen in the background while you sleep. So not never never having a human touch the process from end to end.
Ben Frank: And right now we have different pieces of that process already automated and using AI including the appeal process. We kind of came out of the gate and said the hardest thing is going to be writing these appeal letters efficiently and to the same quality that we’re used to when we manually write them. But we’ve we just launched version two of our appeal tool and it’s the quality of the letters coming out of it is actually better than the letters that we manually wrote. So we we’ve kind of crossed that threshold. Yeah. And so we’re also we’re looking at voice agents so that they can actually have conversations with these payers. But you do bring up a good point on the kind of flip side of Unity, you have these AI systems being used on the payer side. Yeah.
Ben Frank: And the biggest threat there in my opinion is when the clinical decision-making on the insurance side, which they don’t call it clinical decision-making, they just call it utilization management, right? When that is going to become automated, that is a scary thought for me because right now it’s a physician or a nurse reviewer looking at these cases. But you know there’s right now I think it’s just rumors and obviously the United case is a good example. But if there are tools out there that are being developed so that they can not use humans anymore then it’s the quality of those approvals in my opinion will probably go down.
David Raubach: Well and if you think about the ultimate motivation of the insurance company. So let’s take again going back to United Healthcare because they’ve been in the news a lot and they’re also the largest commercial payer in the United States.
Ben Frank: Big dog.
David Raubach: They’re a for-profit company.
Ben Frank: Yep.
David Raubach: Publicly traded. They have an obligation to return money to their shareholders. That is a corporate mandate that they have. Priority number one, shareholder value is to create shareholder value. The best way for them to create shareholder value is to deny coverage. It’s to take payments for insurance plans and then limit the amount of that money that gets returned to their members. Yeah. Absolutely. And so if you’re United Healthcare or you’re any insurance company and you’re building a software program, probably you’re building that software pro and you want it to be more efficient and do a better job than the people that you employed did. You’re probably telling that software program, we denied X number of cases last year. We generated Y profits. We want X plus 10% denials this year. And that’s just how they’re going to be. And there’s no talking back.
David Raubach: There’s no right subjective physician clinical decision-making that goes on. And right now, whether or not there’s good clinical decision-m going on with the medical directors with any of these plans is, you know, questionable just based on the fact that they’re not putting radiation oncologists on radiation oncology cases.
Ben Frank: But you still have another human on the other end of the phone. That, you know, they they have treated patients ideally in the past or most likely in the past. And so they there is some little there’s a little bit of an emotional connection there that you can tap into and there’s a conversation that can be had when you start leveraging technology to do it. It’s just rule-based.
David Raubach: Yeah. And there’s no investigation into the nuances of each individual case. So it’s definitely a little scary, but I don’t think it will be successful in the long run for them because at the end of the day, these plans need members. They need mass population to hit their revenue targets. And I think that there’s so much pressure on them right now, especially in the prior authorization world, that their biggest customers, which are the employers, those ERISA plans that are using them as TPA, they’re going to start moving. They’re going to shop around. And because prior authorization is becoming such a prevalent topic in these sales pitches, and these conversations, that employers are now starting to ask, hey, what’s your prior authorization process? How do you deny patients?
David Raubach: Like if I’m an employer, a large employer, and I have a thousand employees, and I’m looking at any one of these plans to use as my TPA, my first question to them is, well, all right, so what is your denial rate? Yeah.
Ben Frank: On standard of care.
David Raubach: Yeah.
Ben Frank: You know, and because at the end of the day, those employees are going to come back to me, my benefits office. They’re going to look to me and say, why did you deny my care? Right. And I think that is something that is changing and it has been changing over the past decade.
David Raubach: Well, you bring up a good point. If there’s if there’s going to be pressure on payers to not take the trend with AI or the utilization of AI too far, it’s going to have to come from members and it’s going to have to come from employers.
Ben Frank: Yeah.
David Raubach: The customers.
Ben Frank: Yeah.
David Raubach: Yeah. And so educating those employers because I I’ve been involved in the past in the decision to pick a particular insurance company or a particular plan to offer to employees. And a lot of times at that decision-making point in time, you’re just looking at the cost. Yep. What is this going to cost the me as the employer? What is this going to cost my employees? It’s important for employers to think about the downstream costs of having an employee who gets cancer because it’s going to happen. Statistically, it’s going to happen. If you have 50, 100, certainly if you have a thousand employees, somebody’s going to get diagnosed with cancer at some point during their employment. You want that person to get the best treatment possible, right? You want that person to have the fewest side effects possible.
David Raubach: You want that person to be able to come back to work as soon as possible. You want that person to be happy with the experience that they had with their health insurance that they access through the employer. That’s what employers should think about that.
Ben Frank: Yeah. Then they’re starting to
David Raubach: Yeah.
Ben Frank: And the only reason I know that is because I took a side quest between Apollo and Unity to start a company called Wheelhouse. And it was a cancer focused employee benefit basically that really just built a circle of emotional support and community support around patients as they were going through their cancer journey. And but learned a lot about the benefits world building that company up. And one of the things that I learned more is that every year employers are asking more about cancer. They’re asking more about pri authorization, more about denials. So the more that we can educate them and really the HR offices and the benefits offices of these big employers, the more pressure will be applied to these big payers. And so I think we’re at kind of a turning point within our society and there’s obviously a lot of press about it right now, too.
David Raubach: Yeah. No, and that’s a good thing, too. So, what are you wanting Unity, this software program that you’ve built, what do you see it doing two years from now or three years from now?
Ben Frank: Yeah. So ideally, you know, our mission at Unity is to actually eliminate pri authorization. We want to collect enough data, build a streamlined automated process that we can go back to payers and say, “Hey, we have all of this information. You’re denying 70% of our cases. We’re getting 80% of those overturned. You’re wasting money. We’re wasting money. Let’s just let’s eliminate this process for this disease site.” And then as we get more data for the next disease site, we do the same thing. So we can use that data to really start creating transparency not only with providers but with the payers and with the goal of saying, “Hey, let’s just have a fasttrack program. This is just slowing down care. It’s not good for care. You’re we’re you’re wasting money.” Like we can have an economic benefit here and we can have a clinical benefit.
Ben Frank: And we truly believe that, right? At Unity. And what we see long term with our product is that we can be that intermediary. So we can be the data warehouse where payers come in and say, “Hey, you know, we want to connect to you and providers connect to you and as soon as a provider has a patient that needs left breast protons, they submit it to the system and it automatically gets approved to the payer because we have all of the data points right there ready to go and to transfer to the right areas, right? So, you know, that’s there’s a long way to go and a long road before we get there. And a lot of it is going to be collecting data and showing the value of a good appeal process to these providers and the clin the oncology community over the next four or five years.
Ben Frank: But I truly believe that is as we collect that information and we share it with the payers that it will provide benefit to everyone.
David Raubach: Well, and payers want to be more efficient, right, too. I mean, it’s a cost savings for them.
Ben Frank: Yeah. That’s why they’re looking at AI to do the review process.
David Raubach: Yeah. Why go through an initial denial and a first level appeal and a second level appeal and then it’s got to go to external review and they’re paying doctors to look at cases.
Ben Frank: Yeah.
David Raubach: When it’s just ultimately going to get approved.
Ben Frank: Yeah. At external review, go ahead and approve it up front.
David Raubach: Right. Don’t waste the time on it. And you’ve talked as well about branching out into medical oncology.
Ben Frank: Yeah. It’s a kind of new area for us. We’ve, you know, been in radiation oncology for over a decade now. And my partners and I are all radiation oncology experts, but know really nothing about medical oncology. Just the high level tip. But we do know that as these immunotherapy drugs and kind of patient specific therapies are being developed, the denial rates are skyrocketing right now.
David Raubach: Yeah.
Ben Frank: And it and it’s not historically, from what I understand, it’s not historically something that medical oncologists have really stressed over, but it’s becoming more on their radar. And with as the cost of drugs, no surprise, goes up, the denial rate is going to go up with it. And we think that there’s an opportunity there. And the benefit on the medical oncology side is that kudos to medical oncologists and maybe it’s just the kind of nature of the beast, but they collect a lot better data than we do on the radiation side. A lot more randomized trials and good clinical data that we can put in appeal letters. And so preliminary work that we’ve done there shows that our success rate is going to be similar to what we see in radiationology, maybe a little better.
David Raubach: Yeah. Yeah. So there’s a pilot program that Medicare is implementing next year.
Ben Frank: Oh yeah.
David Raubach: To actually do prior authorization. So historically Medicare has had coverage policy. So they’ve said these are the services that are going to be covered. And we as providers know that going in. There’s not really much of an opportunity with Medicare to go through an appeal process. There is, but it’s rare that you would ever even try to pursue it.
Ben Frank: Y, as complicated as the process is with commercial payers, it’s even more complicated to try to appeal a Medicare avoid the government at all cost.
David Raubach: Exactly. So, for me, I’ll just say as a provider, this is a little bit frightening to think about Medicare deciding to get into the prior authorization game. What are you hearing about this or what’s your perspective on this pilot program that they’re implementing and what it could mean down the road?
Ben Frank: Yeah, I’m I would be lying if I said I wasn’t a little concerned about it.
David Raubach: Yeah.
Ben Frank: I think it’s very surprising to me that the government is making a decision to add a utilization management program that has been plaguing patients in the commercial space for so long.
David Raubach: Yeah.
Ben Frank: But at the same time, I’m trying to remain optimistic that maybe they’re going to try and implement processes there and tools there that will streamline it and that implementation could be used in the commercial space as a maybe even a regulatory kind of push to say, hey, here’s our national prior authorization process. But there’s still so many unknowns with it that it’s kind of like just waiting and hoping that it’s not going to be detrimental. But yeah, I mean I’m it it’s definitely given me a little bit of heartburn. Let’s put it that. We’re all We are all a little bit nervous. Yeah. About how it’s going to get rolled out and just what it’s going to look like because again it’s the thought of going through this multi-level appeal process with the federal government and all of the bureaucracy that exists there is it’s a little bit terrifying.
David Raubach: What so talk a little bit too about the changes in the way that treatments are paid for with radiation oncology. How are how have historically treatments been paid for and what is the trend moving forward?
Ben Frank: Yeah. So historically the way doctors are reimbursed for protons or IMRT or whatever it may be is per fraction. So there’s some ancillary services that happen before you start treatment like your simulation or the treatment plan itself being developed. Some sim, you know, some consultations and doctor visits, things like that. But the primary bulk of the reimbursement happens when you come in for your treatment on a day-to-day basis. And every single day is a charge is a individual call it an invoice for layman’s terms. And so that process can you know if you have a long treatment course that can add up to a lot of charges over time and it can be very cumbersome, very complicated. And so what the talk right now within the government and within some commercial payers is that hey it would be a lot easier if we just started bundling these.
Ben Frank: And the other factor driving this is that Dr. A might treat prostate cancer with 20 fractions and Dr. B might treat prostate cancer with over 30 fractions. And so there’s also a nuance to it where these payers and the government are saying hey well what’s the clinical benefit here if you have you know intermediate risk prostate you same Gleason score basically virtually the same patient but you’re treating two different ways why right and one’s obviously significantly more costly to us as the payer [snorts] and so what is happening now is they’re saying what if we just gave you a bundle one one code for the entire course of treatment or Maybe just a few codes for the entire course of treatment. And you can do whatever you want, right? You can treat with as many fractions as you want. You can treat with five fractions, 20 fractions, exactly 30 treatments.
Ben Frank: We don’t care. Whatever is best for the patient and that is going to incentivize more efficient delivery of care in my opinion. I think it’s a good thing for our industry. It’s going to create some growing pains, especially in the proton specialty. But I think as long as we can learn from it and carve out certain things along the way to protect the practices so that we don’t have practices going out of business, then I think that it will ultimately be a good thing for patients and it will be a good thing for the specialty as well because right now it’s just getting more and more complicated. We need to simplify things, right? So yeah, I mean it’s bundle payments are the future for sure.
David Raubach: Yeah, and I think it’s important to talk about why there might be differences in the delivery of radiation. So, historically, we didn’t necessarily have all of the tools that we have today to be as precise with radiation as possible. And so, you were delivering a lot of radiation to the body. You’re delivering a lot of radiation to the tumor, but you’re also delivering a lot of radiation to healthy tissue. Yeah. And critical organs. And so 20, 30, 40 years ago, the thinking was to be able to safely do this, we need to deliver very small doses each day. We need to fractionate over a long period of time. Over a long period of time. There’s a there’s a prescriptive dose.
David Raubach: There’s a total amount of radiation that we know eventually needs to get to the cancer cells to completely kill all of the cancer cells, but we need to spread that out so the patient can tolerate that delivery. As we’ve gotten more precise, both on the photon side, traditional radiation side, and with proton therapy, we do have more of a an ability to deliver higher doses each day and the patient be able to tolerate that. And that’s especially the case with protons because you’re stopping that radiation inside the tumor. You’re not getting dose beyond the tumor. So, there’s just a lot less radiation that is hitting healthy tissue. But as you pointed out, because historically we’ve paid on a per treatment basis, if you deliver 20 treatments instead of 40 treatments, you’re getting half the amount of money from the payer. Y and radiation oncology has significant capital costs.
David Raubach: Proton therapy has very significant capital costs. A single proton room, even today, the total project may be 40 or $50 million.
Ben Frank: Yeah. And so there has to be this kind of meeting in the middle where the payers say, “We’re agreeing to pay you a certain amount of money that’s going to allow you to implement new technology like proton therapy. It’s also going to be convenient for the patient.” And then the doctor says, “Okay, well this is going to allow us to hypractionate but also have a viable business.” Yeah. No margin, no mission.
David Raubach: Meaning
Ben Frank: Exactly. If you can’t cover your costs again at a proton center, you can’t have the proton center exist, right? You have to be able to cover those costs.
David Raubach: And finding that balance, it’s going to be challenging, but I agree with you. I think it’s best for the industry long term.
Ben Frank: Yeah. Yeah. I think it’s going to take some learning, but ultimately it’s the right move, and it will bring down administrative costs as well. So billing for radiation ooncology will become much simpler and right now billing is a you know it could be 5% of your total revenue that you just spend on administrative costs just for billing right just for that one piece and so you know there’s different areas where I think we will see advantages the other thing is throughput so if this incentivizes more hyperfractionated less fraction less treatments per total course then what that means is that any individual machine any individual proton center can now increase the number of patients that you can treat at that facility.
Ben Frank: And if simultaneously you have an economic advantage and payers are buying on ideally, then you can eliminate those kind of prior authorization issues, you can eliminate those access issues that currently exist and just start funneling as many patients as you can into the system. I think there will be some short-term pains there. Obviously there’s, you know, it might indicate that we have more linacs in the country than we need, right? You know, but you know, I think long term it would be a good thing for patients. Yeah. And that’s and then there to your point with that, you know, there’s the risk of some facilities shutting down which creates an access issue, a local access issue for patients. And here in Oklahoma, we’re depending on the cancer diagnosis, we’re somewhere between 48th and 50th. So somewhere between third to last, second to last, or last in cancer mortality.
Ben Frank: Meaning if you get diagnosed with cancer in Oklahoma, you have some of the worst outcomes. But part of that is access. We’re a heav he heavily rural state. There aren’t linear accelerators in some of these rural towns. So, how do you still kind of create that access for patients? And I don’t know what all the answers are to that. Certainly the payer reform and making sure that payments work for patients and for providers and for insurance companies, that’s part of it. Yeah.
David Raubach: Physician coverage is another big one.
Ben Frank: Yeah. And that’s a hot topic right now within our industry as well. Yeah. Physician reimbursement is a it’s a big deal. You have to sufficiently pay physicians to deliver the care. Yeah. We need more people going into radiation oncology. We need more specialists. We need more medical physicists. We need more radiation therapists. There’s a staffing shortage in radiation oncology.
David Raubach: So just to kind of wrap up today, I think you know we have spent a good part of our careers in the proton therapy world. I would say we’re both pretty optimistic about the future of proton therapy. You would agree with that?
Ben Frank: Yeah. Yeah, definitely. I mean just looking at the technology that’s being developed right now, I mean the FIT system is a good example. What Leo Cancer Care has done with their upright system and Mevion coming in with their cyclotron is I mean it’s really changing the game and changing the conversation on who has access to protons now as far as hospital systems go as providers go and I think as the cost capital cost and startup cost of these proton centers becomes lower and lower you’ll have more centers developed there are centers being developed all across the country as we speak but that volume will increase and as we have more volume we’ll have more leverage we’ll have more conversations around protons. We’ll have more physicians buying into proton therapy as a modality. And I think that’s only going to be a good thing for us.
Ben Frank: And with that, we’ll have more access to trials. We’ll have more data. We’ll have more disease sites being treated with protons. And hopefully we’ll have more access via the payers if Unity is successful.
David Raubach: And you’ve seen positive trends on the reimbursement side from a coverage standpoint and on the clinical research side as well.
Ben Frank: From a clinical research perspective, yes, on the reimbursement side, I’ve seen positive advancements in the commercial space, surprisingly in some geographic locations, but unfortunately, there’s been some negative movement actually in my location in Tennessee, with government reimbursement, for Medicare reimbursement. So, our MAC has changed their payment rates, had decreased them pretty almost arbitrarily, pretty significantly. And it’s, you know, it definitely has an impact and it this kind of like hemming and hawing that we see in the reimbursement world is unsettling for sure. But I think I think everyone in my opinion is just trying to wrap their heads around protons still, even though we’ve been around since the ’90s, this modality. The volume of proton centers is obviously increasing and the number of these utilization requests and prior auth requests going into these payers and claims going into the payers is increasing.
Ben Frank: And so I think everyone is just trying to say okay protons is becoming like it’s got its foothold now.
David Raubach: Yeah. Like let’s start putting some structure. Well you were at I mean MD Anderson was what proton center four three I think two or three.
Ben Frank: Yeah one of the earlier proton centers and then Knoxville was the 13th proton center.
David Raubach: Y I can’t remember what Nashville was.
Ben Frank: Somewhere around 30 I think.
David Raubach: Yeah 30. I think today there’s 50ish.
Ben Frank: It’s approaching that number for sure.
David Raubach: Yeah getting close to 50 proton centers with multiple more in development. It very much is becoming a standard of care for a lot of disease sites.
Ben Frank: Oh yeah. Yeah. I mean, even if you look at like Louisiana, for example, they just passed a law, I think in the past year that basically pegs I think it’s pegs commercial insurance medical policies have to be aligned with ASTRO model policy. Okay. And ASTRO’s model policy is very generous in my opinion. I mean, between group one and group two indications, you have a pretty large cohort of patients right there. As long as you have access to trials and clinical registries within your center, group two can, you know, that’s a big big group of patients that you can tap into.
David Raubach: Yeah. And maybe explain that. So, group one, group two, what does that mean?
Ben Frank: So, group one indications, ASTRO is basically saying these are these are great cases. They should be treated with protons. Group two indications, they’re saying these may be good cases. You should use your best clinical judgment. And then if they’re on a trial or on a clinical registry, let’s study it. Let’s open the door for these these disease sites. And those are things like breast cancer and some other kind of what I would call controversial disease sites. But yeah, you know, if you can get access to group one and group two indications in your proton center, that’s a big deal.
David Raubach: Y and so kudos for Louisiana for pushing that legislation through. And hopefully we can see other states doing the same thing or even better, maybe these payers will start doing it because we’re definitely starting to see some ASTRO model policy language falling into these these big bigger payer medical policies.
Ben Frank: It makes logical sense.
David Raubach: Yep. Anytime there’s there’s no benefit to excess radiation to healthy tissue.
Ben Frank: Yeah. No one wants it.
David Raubach: You nobody wants it. You can argue about the impact for a particular patient and could their body tolerate that excess radiation but at the end of the day there’s no logic to only bad things can happen if you deliver extra unnecessary radiation to healthy tissue.
Ben Frank: Correct.
David Raubach: So why not offer broad coverage to something like proton therapy and then as you pointed out the costs are coming down to implement proton therapy and that’s going to just create more access down the road.
Ben Frank: Yeah. Yeah.
David Raubach: Well, I really appreciate your time, Ben. There’s not many people that understand the nuances of insurance and insurance coverage and the prior authorization process like you do. There’s also very few people that are really legitimately doing something about it and working to try to create more access for patients. On behalf of the Oklahoma Proton Center, I want to thank you for everything you’ve done for us and everything that you’re going to continue to do and I’m really excited to see where Unity goes from here and everything else that you’re going to do as an entrepreneur in this field.
Ben Frank: Yeah, thank you for having me and likewise, thank you for always trusting us. You know, you’re client number one for Apollos. We owe you guys a lot.
David Raubach: Yeah. Well, we want to be client number one for whatever is next as well. Well, thanks, Ben.
Ben Frank: Yeah, absolutely. Thank you.
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