Date of Conferral
7-30-2026
Date of Award
July 2026
Degree
Doctor of Nursing Practice (DNP)
School
Nursing
Advisor
Susan Huehn
Abstract
This organizational process evaluation project addressed the high rate of insurance denials for hormone replacement therapy (HRT) for women with symptomatic menopause and "normal" laboratory values within a private primary care setting. The practice problem involved bureaucratic barriers in the front office and a lack of structured advocacy, which delayed patient access to evidence-based care. The purpose of this project was to evaluate the impact of a streamlined insurance advocacy and pre-authorization process on access to therapy. The project utilized a standardized "Insurance Advocacy Toolkit" and evidence-based templates aligned with the 2023 North American Menopause Society (NAMS) guidelines. Analytical strategies included a pre- and post-implementation comparison of insurance approval vs. denial rates over a 4-week period and an assessment of staff competency in documenting medical necessity. Findings indicated that structured advocacy and nurse-led follow-up effectively overcome external insurance forces. Implementation resulted in a 100% staff competency rate and a reduction of initial pended claims to 13%, exceeding the project goal. Major products developed included the Payer Advocacy Toolkit and integrated electronic health record symptom-tracking markers. Recommendations include the permanent adoption of the toolkit to "hold the gains" in office efficiency. Potential implications for nursing practice include improved provider-payer communication and increased health equity through reduced patient out-of-pocket costs and improved symptom management.
Recommended Citation
Edwards, Ellison, "Evaluation of a Streamlined Insurance Advocacy and Pre-authorization Process for Hormone Replacement Therapy" (2026). Walden Dissertations and Doctoral Studies. 20450.
https://scholarworks.waldenu.edu/dissertations/20450
