Otolaryngology Practices Use Digital Tools to Pre-authorize—With Mixed Results

A patient at ENT and Allergy Associates—a practice with 56 locations across New York, New Jersey, and other states—was scheduled for surgery one day in late December. The patient was eager to have the procedure done that day as planned, because they had time off work and had met their deductible for the year.

But there was a sudden problem with the insurance coverage. The address for the location of the physician doing the procedure hadn’t been altered correctly by the insurer, so the coverage was now in question. So, it fell to Margaret Hargrove, ENT and Allergy’s vice president of revenue cycle management, to get on the phone with the insurance carrier’s representatives to try to resolve the situation—and fast.

It wasn’t supposed to be that way. The prior authorization had been done electronically through Availity, a system used to upload records and meant to streamline the prior authorization process—advance approval of insurance coverage that’s needed before medical care is provided. It’s a process that’s now required for many more procedures and other medical care than ever before and, physicians and practice managers say, that often is also a more cumbersome and frustrating process than ever before.

When it comes to digital platforms meant to ease the prior approval burden, practice managers describe a two-sided coin: Many procedures can receive almost instantaneous approval after a few keyboard clicks when that was never possible before, a welcome advancement that frees up staff members to be able to do other things. But when a case isn’t cookie-cutter, these tools often aren’t very helpful—and might even make the process more of a headache than it would have been back in the old days.

Automation Benefits and Drawbacks

“The problem is, when you’re using this automation stuff, it’s great if you’re assuming that their credentialing team (for the insurance provider) did everything they were supposed to, and all the locations are right and they didn’t make any mistakes on their side,” Hargrove said. “But if there’s any kind of different situation or scenario that you need to speak to somebody about, there’s always hiccups.”

AHIP, a Washington-based association representing insurance companies, recently started an initiative called Fast PATH, a campaign to encourage medical providers to use electronic platforms for the prior authorization process. In describing the initiative, the organization acknowledged the burden of prior authorization and says it’s working toward a solution.