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 19–45), 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
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. 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.
Ben Frank: Yeah, thank you so much for joining — for having me. So I want to start at the beginning. 2014, you’re at MD Anderson. Why did you go into oncology at that point?
Ben Frank: Yeah, good question. Like many people, I was affected by cancer early on in my life — different family members had it, had to experience that as a young child. But more importantly, when I was about 13, I had a blood disorder — pretty rare blood disorder — and ended up spending better part of a year in an oncology practice, a pediatric oncology practice, because the only hematologist in my community was also a pediatric oncologist. I got to experience what it was like sitting in a waiting room, sitting in an infusion suite with other kids that were going through cancer. I got to know a lot of those patients, became friends with them, and it just sparked something in me. I knew I wanted to go into oncology, and that’s what drove me to pursuing a fellowship at MD Anderson.
David Raubach: So when you were doing the pediatric treatments, where was that?
Ben Frank: That was in Columbia, South Carolina. My blood disorder was relatively benign compared to what those kids were going through. So I had this weird experience where my life wasn’t in danger, but I still had to go into this clinic on a weekly basis and sit there with them. I got to see that from a different perspective — being a patient, but not being scared — and got to almost see their fear and talk to them through it as a teenager. It just had a lasting impact on my life.
David Raubach: And so then you did an undergrad in business, and then grad school for healthcare administration at the Medical University of South Carolina. One of the paths you can take when you’re doing an MHA is to do a fellowship — a post-grad training at one of the big academic centers. MD Anderson is one of the top locations for that. How did you end up there?
Ben Frank: Honestly, by just dumb luck. I got accepted, but I wasn’t even the top candidate. They picked three candidates every year. I was ranked number four out of the cohort that interviewed, and one of the people ended up backing out. So just through luck I got in, and I think back on that a lot now.
David Raubach: What was it like being at MD Anderson? It’s an incredibly impressive campus, and it’s widely considered to be the top research cancer center in the country and really by many rankings the world. It must have been awe-inspiring being on this campus with some of the top doctors.
Ben Frank: Yeah. When you work at Anderson, you get to experience everything that an oncology center could experience over ten years in like a one-month timeline. They have the rarest diagnoses that come there, and they have the top doctors, the best labs, the best imaging, everything you could imagine. It’s not realistic to expect what you have at MD Anderson to exist everywhere, but when you work there, you kind of have to pinch yourself every day when you go in.
David Raubach: What did you learn there that was different or eye-opening compared to your experience as a patient in a hematology setting?
Ben Frank: I think one of the first things I realized was going to be important throughout my career was the effect of a truly multidisciplinary approach to care — when you have a surgeon and a radiation oncologist and a medical oncologist all working together, even radiology and pathology together on a patient. In Columbia as a patient, those doctors never even really talked to each other. It was siloed in the community setting. Seeing that happen in real time at MD Anderson — sitting in grand rounds, watching these peer-to-peer conversations about patients — I thought, “Oh wow, this is a completely different way to deliver medicine.”
David Raubach: Did you have exposure to their proton center while you were there?
Ben Frank: Yeah, actually the proton center was my first introduction to radiation oncology. The preceptor for the fellowship that year was Tom Buckolds — he was the physician chief and a radiation oncologist. He connected us in the radiation oncology division, and a guy named Matt Palmer was kind of our partner in the fellowship program who really showed us around the proton center and had us working on a project with him — letters of medical necessity — which was my first introduction to insurance issues. That is where my interest really just sparked. And then we also had a fellow who was a clinical resident, Nick Hillaker, a radiation oncology resident, and just got to learn a lot from him by sitting desk-to-desk.
David Raubach: That’s interesting — insurance approval and prior authorization while you’re at MD Anderson. I would think if MD Anderson says a patient needs a particular treatment, that’s just an automatic yes.
Ben Frank: Not so. Even at MD Anderson they struggle with getting insurance approval. General rule of thumb is the larger the health care system, the more leverage they have with payers and the easier the process generally. But it’s not always a slam dunk. 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 it’s not a clinical decision — 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.
David Raubach: What were some things you learned about the process at MD Anderson that you took away and wanted to apply in the community setting?
Ben Frank: Really breaking the process down in a militaristic format. I give a lot of credit to Dr. Asha — a physician at the Proton Center who had previously been at a payer as a medical director. He had this really deep knowledge on the process of prior authorization and utilization management, and he taught me that you have to have a very defined process and you have to understand the regulations like the back of your hand — federal regulations, state regulations, which differ by payer, by the type of plan, by the location of the practice. What MD Anderson did was really understand intricately every single case and follow that process to a tee, and that always results in better outcomes, better approval rates, better overturn rates for denials.
David Raubach: So from MD Anderson you moved to Nashville. Talk a little bit about that transition and how you ended up at the Proton Center there.
Ben Frank: That was a big move. And weirdly enough, you are the reason I was in Nashville. My boss at MD Anderson at the time — Robert Gafar — was sitting next to you at a conference, I think the RaySearch users meeting in New York City. He knew I was going to be moving to Nashville because my wife got a promotion to the corporate office for her company, and I called you. You said you were building a proton center in Nashville with Provision, and that’s how I ended up there. I was employee number one at that location.
David Raubach: Right — I was the VP of business development at Provision Healthcare, helping get the Nashville proton center off the ground after we already had the Knoxville center open since 2013. We needed someone with a strong operations background, and you started as director or VP of operations. We had Jim Gray as medical director on the clinical side. And you also got your first real opportunity to apply what you learned about the insurance process from MD Anderson.
Ben Frank: Yes. When we started the proton center in Nashville, we took the model that was being used at the Knoxville Proton Center and applied it — it wasn’t a bad process, and they had a really good success rate. But through some conversations, I convinced Dr. Asha from the Proton Center at MD Anderson to move up to Nashville to help run the proton center and really reshape the way that we approached prior authorization. That’s where I really learned: this goes a lot deeper than what we’re doing right now. In the private practice world compared to MD Anderson, you don’t have that same leverage with the payers — you’re starting behind the eight ball a little bit. But nonetheless, we were still achieving the same overturn rates that some of the most successful proton centers were getting, and that proved to me there was something to this.
David Raubach: For listeners who maybe haven’t gone through getting treated for cancer and having to get insurance approval, walk through the steps a patient experiences and what you were doing on the back end to try to get that approval — especially in a situation where there’s an upfront denial.
Ben Frank: When you go into a consultation with your physician and they decide they want to treat you with protons, the next step is getting authorization from the insurance company. That process can be simple — maybe three days: the insurance company says yes, you’re good to go. When it’s not a covered indication — take breast cancer in proton therapy as an example — they’ll deny it. And unfortunately a lot of physicians and practices around the US, when they get that denial, just go back to the patient and say, “I’m sorry, you were denied. You can either downgrade to IMRT or pay out of pocket.” That can be devastating for a cancer patient, and that is one of the biggest things that motivates me — I hate that conversation.
Ben Frank: When you can go back to that patient and say, “You got denied, but we also have this federally regulated appeal process where we can appeal that denial through multiple levels, ultimately getting outside of the insurance company entirely,” it changes the mindset of the patient. Once we get the denial, we either have a peer-to-peer where the physician talks to their physician — hit or miss depending on who’s on the phone — or we write an appeal letter. These letters can be short. In a typical practice they’re probably one-page templates not really giving context. In our scenario, we were writing very long, detailed letters on why this should be approved, using research, using clinical justification, even social factors specific to the patient’s individual case.
Ben Frank: That appeal structure is what ultimately leads to success. There are three levels: Level 1, Level 2, and IRO — the Independent Review Organization. The ultimate success metric in my opinion is getting to IRO, which means it is out of the payer’s hands. You’re talking to someone who’s non-biased, looking at all the facts — the clinical case, the medical policy, whatever is relevant — and making a decision. What we found is that if you build a story of appeal arguments over time across Level 1, Level 2, and then external review, the success rate at external review goes up significantly. It pays dividends to invest that time through the appeal process.
David Raubach: Let’s use a left-sided breast cancer case as an example — treating the chest wall after mastectomy with lymph nodes involved. That’s a big area getting radiation in close proximity to the heart. For whatever reason the insurance company doesn’t have that on their coverage policy. The doctor says proton therapy is the better option. What is going into those appeal letters for that particular case?
Ben Frank: For a left-sided breast case, we would bring in specific research related to dose to heart. When you’re using photons, sometimes the distribution of radiation to the organs at risk can be significant enough that proton therapy is justified. We bring in research showing there’s been historical analysis done on multiple cases demonstrating we can reduce heart dose using proton therapy compared to photons. We also create a comparative plan — a dosimetrist creates both a photon plan and a proton plan and we compare the dose delivered to the heart in each. We then compare that delta to Quantec dose limits, which is a gold-standard library of organs at risk and the dose you can deliver to that organ without causing significant damage. There’s also the Darby paper — a famous study showing significant increase in cardiac events based on heart dose received — that we would reference as independent clinical data.
Ben Frank: We put together what’s called a color wash — basically shows the beams and how radiation is being distributed across the body — for the insurance company and the external review organization to see. Clearly in the photon image you can see dose going through the heart; in the proton plan you can see conformal distribution with the heart completely avoided. Sometimes that is enough. Sometimes it’s not. But in some circumstances depending on the patient’s anatomy, prior radiation history, or other factors, the photon plan could be a very bad situation for that patient.
David Raubach: You also mentioned being patient-specific. What do you mean by individualized appeal letters?
Ben Frank: Every patient’s case is different — their anatomy, their specific diagnosis, their treatment plan, their health plan. You can’t just use a template for every left-sided breast case and expect insurance companies to overturn those denials. They want to see real justification on why this specific patient needs protons. You have to dive deep into the patient’s case — understand why they need protons dosimetrically, but also from a socioeconomic perspective. They might not be anywhere near a photon practice; we’ve used those arguments in appeal letters. Age is another one. In a younger patient — the AYA population, roughly ages 19 to 45 — you have a longer life to live, meaning late effects from radiation exposure will be experienced in a way an older patient may never see. If you fall within that group, I would say you definitely need to be considering protons.
David Raubach: One thing I’ve noticed reading some of your appeal letters is that you understand it’s not always a radiation oncologist reviewing all the information. You always did a good job of writing in a way that a primary care physician or a surgeon — someone not familiar with radiation oncology — could understand.
Ben Frank: Yeah. When we started this process it was not uncommon to be arguing against an ER doctor for a radiation oncology case who had very little insight on what proton therapy was or the difference between protons and photons. That can be extremely frustrating. There are a lot of different barriers on the payer side that are, in my opinion, specifically designed to dissuade people from pursuing appeals — make it more cumbersome, make it bureaucratic. What we did in my first company, Apollo, was take that head-on. We said we’re going to be the antithesis of whatever they’re doing. We’re going to fight fire with fire.
David Raubach: Talk a little bit about starting Apollo. I remember we had a conversation in Chicago at a rooftop bar at the ASTRO conference. You told me you had this idea, and I said go for it. I think I was the validation you needed.
Ben Frank: That conversation really did validate the concept. I remember asking you: if this service existed and this is what we could achieve, is that something you as an operator of a proton center would want to engage with? And you said, “Yeah, of course. Why wouldn’t we want to get more cases approved?” So that was the start of it. Shortly thereafter my time at Provision was coming to an end, and I knew there was an entrepreneurial spirit inside of me that I wanted to explore. I left to start Apollo with my partner Chris Gonzalez, and we just started in our spare bedrooms working on proton cases. You guys were client number one. It started with an idea and we adapted it over the next few years and took over a pretty good portion of the proton centers in the United States.
David Raubach: You brought up Chris — that’s an interesting partnership because you had the business side, the MHA, the MD Anderson fellowship, but he was a dosimetrist. Why did you partner with a dosimetrist for this particular endeavor?
Ben Frank: Getting back to what Dr. Asha specifically taught us about prior authorization: one of the key variables on successful prior authorization is having someone who intricately knows the clinical side of the argument. In our world, dosimetrists are the best clinicians to take that argument on because they’re the ones making the plans — they know the dosimetry very well. The best way to understand a dosimetrist is to think of them as the pharmacist for radiation. They have this really deep intricate knowledge of the science and the modality being delivered. If you can teach those people prior authorization and appeals, they’re really unstoppable. Chris was trained in this process and knew it really well. We married together as this perfect partnership to grow Apollo.
David Raubach: Talk about some of the quirks and intricacies of the regulatory process — things you always had to keep in mind around the paperwork and the timing of filing appeals.
Ben Frank: The biggest rule that anyone looking at prior authorization needs to know is ERISA. If you have an employer-sponsored health plan, there are federally regulated processes for prior authorization, and that’s a big chunk of American healthcare — about 60% or so of commercial plans. When we started this, we realized that plans rarely followed ERISA rules, because no one was overseeing them or calling them out on it. For urgent cases — which most cancer diagnoses are — ERISA requires a 72-hour turnaround at every appeal milestone. What we were noticing is that they weren’t responding in 72 hours; it might take a week or more. But what we learned is that if you submit an appeal letter on that 72-hour mark, even before you formally get the denial, and state, “We notice it’s been 72 hours; here is the specific ERISA law you violated,” a lot of times they’ll reach back out pretty quickly and say, “Oh, this is now approved.”
David Raubach: The worst thing that can happen for an insurance company is to break the law. That creates real liability. And you would literally write the rule or the law into the letter.
Ben Frank: We made sure all relevant information was in the letter — the law, clinical research, even specific health plan clauses. Employer-sponsored self-funded plans can have their own unique processes even more strict than what ERISA governs. You have to get your SPDs — the summary plan documents every employer gives employees outlining their benefits — and also look at the health plan and the medical policy. There are all sorts of rules you have to be aware of. Over time, the same people doing this start to know these things by heart, know the direct lines to medical reviewers at the bigger plans, know the tips and tricks. Timing is the biggest thing that helps us.
David Raubach: One of the tactics we’ve noticed insurance companies will use is denial by delay. Tell me what that means in your world.
Ben Frank: Prior authorization denials and the appeal process could easily extend out to 60 days or more, simply from the insurance company not responding to your appeal letter. What that means is they’re hoping the case is so urgent — it’s cancer, so you have to get the patient on treatment ideally as soon as possible — that the physician will become so agitated and the patient will become so agitated that they’ll just compromise and accept a lesser modality. That is denial by delay. We don’t want that to happen. We want whatever the physician has prescribed to be delivered to the patient. The insurance company knows that if they delay things long enough, you won’t have a choice. And then they can say, “Well, we never denied the case — the patient chose to accept a different treatment.”
Ben Frank: The way you combat it is speed — holding them accountable to those timelines and then matching their speed. If ERISA says every 72 hours, your timelines have to be faster than 72 hours. It’s a lot of work to cram into a short timeline, but what we’ve noticed is that at first insurance companies are taken aback by our speed and the depth of our appeal letters. Over time they start matching our speed because they know we’re not going to let them sleep on it. You do not let those timelines slip because you will have patients fall through the cracks — patients that get too agitated and stressed out and will rightfully want to downgrade their treatment.
David Raubach: You’ve spent a lot of time navigating this process and communicating with patients in a high-stress situation. A patient has cancer, they’re potentially facing big medical bills, and a course of proton therapy may cost $40,000, $50,000, even $100,000. What are your conversations like with patients to help ease their burden?
Ben Frank: We use a lot of data now because we have data that helps us understand what their likelihood of getting their case overturned actually 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 can actually show patients: here is your likelihood of getting approval. But also staying in communication with those patients at every step along the way is critical. What typically happens in a community setting is there’s usually one person working on prior authorization, completely overworked and overwhelmed, not having time to call every patient with every update. With Apollo, we made it a priority to let every patient know every 72 hours what’s going on with their case — the good and the bad — so they can have relevant conversations with their physicians. Providers are also getting those updates from us. I think that transparency is really the only way you can ease those stressors.
David Raubach: How have you seen AI impact this whole process — both on the positive side with your data collection work, and on the negative side where we saw the United Healthcare controversy of using an AI platform that was automatically denying cases without a human even reviewing them?
Ben Frank: In the early days of Apollo we knew we had to have a digital platform to scale the service. To scale a solution completely driven by clinicians is really hard — cancer practices can’t afford to hire a full-time dosimetrist just for prior authorizations. So we started building something internally, implementing automations, taking knowledge out of our heads and putting it into a tool that can automate as many steps as possible. Over time our customers saw this system at grand rounds and other meetings and said, “What’s that? I want to use that.” So we commercialized it a couple years ago and called it Unity. Our vision for Unity is that in the not-so-distant future, this entire process — including all the appeal timelines — will happen in the background while you sleep, with never a human touching the process from end to end. We just launched Version 2 of our appeal tool, and the quality of the letters coming out of it is actually better than what we manually wrote. We’ve crossed that threshold. We’re also looking at voice agents that can have conversations directly with payers.
Ben Frank: On the flip side, you have these AI systems being used on the payer side. The biggest threat in my opinion is when clinical decision-making — what they call utilization management — becomes automated. Right now it’s a physician or nurse reviewer looking at these cases. If there are tools being developed so they no longer need humans, the quality of those approvals will probably go down. The United Healthcare case is a good example. These companies are for-profit, publicly traded, with an obligation to return money to shareholders — and they may be telling that software program, “We denied X cases last year; we want X plus 10% denials this year.” There’s no subjective clinical judgment, no emotional connection, no nuanced conversation to be had. That’s a little scary.
David Raubach: If there’s going to be pressure on payers not to take AI denials too far, it has to come from members and from employers. Educating those employers is critical because when you’re choosing a health plan for your employees, you’re often just looking at cost. But employers should think about the downstream costs of having an employee who gets cancer — because statistically, if you have 50, 100, a thousand employees, someone is going to get diagnosed with cancer. You want that person to get the best treatment, have the fewest side effects, and come back to work as soon as possible.
Ben Frank: Absolutely. I took a side quest between Apollo and Unity to start a company called Wheelhouse — a cancer-focused employee benefit that built a circle of emotional and community support around patients going through their cancer journey. I learned a lot about the benefits world building that company. One thing I learned clearly is that every year employers are asking more about cancer, more about prior authorization, more about denial rates. The more we can educate HR offices and benefits offices at large employers, the more pressure will be applied to these big payers. We’re at a turning point in our society, and there’s obviously a lot of press about it right now, too.
David Raubach: What do you see Unity doing two or three years from now?
Ben Frank: Ideally our mission at Unity is to actually eliminate prior authorization. We want to collect enough data, build a streamlined automated process, and go back to payers and say, “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 eliminate this process for this disease site.” Then as we get more data for the next disease site, we do the same thing. We can use that data to create transparency with providers and payers alike. Long term we see Unity as the intermediary — the data warehouse where payers and providers connect, and as soon as a provider has a patient that needs left-sided breast protons, they submit to the system and it automatically gets approved because all the data points are right there. There’s a long road to get there, but I truly believe it will provide benefit to everyone.
David Raubach: There’s also a pilot program that Medicare is implementing around prior authorization. Historically Medicare has had coverage policies — they’ve said these services are covered and providers know that going in. Now they’re getting into the prior authorization game. As a provider, that’s a little frightening. What’s your perspective?
Ben Frank: I would be lying if I said I wasn’t a little concerned. 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. At the same time, I’m trying to remain optimistic that maybe they’ll implement processes there that will streamline things, and that implementation could even serve as a regulatory push — here’s our national prior authorization standard. But there are still so many unknowns. The thought of going through a multi-level appeal process with the federal government and all the bureaucracy that exists there is a little terrifying. We’re all nervous about how it’s going to get rolled out.
David Raubach: Talk a little bit about the changes in the way that radiation treatments are paid for and the trend toward bundled payments.
Ben Frank: Historically, doctors are reimbursed for protons or IMRT on a per-fraction basis — every single day is an individual charge. That can add up to a lot of charges over a long treatment course and gets very complicated. What the talk right now within the government and some commercial payers is: what if we just started bundling these? There’s also a clinical nuance driving this — one doctor might treat prostate cancer with 20 fractions and another with 30-plus. Payers and the government are asking: what’s the clinical benefit there? Why are we paying significantly more for what is essentially the same patient outcome? The proposal is to give providers one code, or just a few codes, for the entire course of treatment — treat with as many fractions as you want, whatever is best for the patient — and that is going to incentivize more efficient delivery of care.
David Raubach: Well I really appreciate your time, Ben. There are very few people who understand the nuances of insurance coverage and the prior authorization process like you do. There are also very few people who are really legitimately doing something about it and working 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 you’re going to continue to do. I’m really excited to see where Unity goes from here.
Ben Frank: Thank you for having me, and likewise — thank you for always trusting us. You’re client number one for Apollo. We owe you guys a lot.
David Raubach: Well, we want to be client number one for whatever is next as well. Thanks, Ben.
Ben Frank: Yeah, absolutely. Thank you.
Join a Community That Cares
Get weekly stories, research updates, and ways to get involved.