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.
Explore This IssueNovember 2023
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.
“Prior authorization can help ensure that patients have access to safe, effective, affordable, high-quality care by helping to guard against potential overtreatment or inappropriate treatments that contribute to unnecessary costs and/or potential harm to patients,” an AHIP document says. “However, there is agreement that prior authorization can be burdensome to providers, consumers, and health plans alike. …Increasing the adoption of electronic prior authorization was one of the five major opportunities identified for improving the prior authorization process.”
In the Fast PATH pilot program, AHIP says a “subset” of providers for six insurance plans began using Availity for medical services and Surescripts, a platform for electronic prior authorization, for prescriptions. A survey that elicited responses from 309 providers on at least one survey question described the benefits of the two platforms. According to the results, during the six months after providers began using the electronic platforms, 62% of all prior authorizations were done electronically. That was a drop of 48% in the number of prior authorizations that were performed manually, and providers reported a 34% increase in prior authorizations performed overall during that period.
Before incorporating electronic platforms into their procedures, 17% of prior authorization decisions were received in two hours or less, respondents reported, according to AHIP. That rose to 33% in the six months after starting the pilot program. Before the program, 61% of prior authorization decisions were received within 24 hours. After starting, that number rose to 71% over the first six months. In addition, before the program, 24% of prior authorization decisions took more than two days. During the six months after starting the program, only 15% of decisions took more than two days.
While the number of prior authorizations performed through electronic means is climbing, many are still done manually, according to AHIP. In a survey performed last year, insurance providers reported that 39% of prior authorizations on medications and 60% of prior authorizations for medical services were performed manually.
The insurance companies reported that 71% of the insurance plans surveyed said that the providers’ electronic health record (EHR) isn’t enabled to perform electronic prior authorizations and that it would be too costly or burdensome for the providers to buy a new EHR platform or update an existing one to allow pre-authorizations to be done.
AHIP did not make a representative available for this article to discuss the prior authorization process and related digital tools or to respond to physicians’ concerns that the burden of prior authorization is growing, although the group did offer statements:
David Allen, director of communications and public relations for AHIP, said, “AHIP has a wealth of prior authorizations and other tools,” and pointed to the survey results and other insurance industry reports.
Kristine Grow, AHIP’s senior vice president of communications and public affairs, noted that AHIP “does not endorse any specific prior authorization platform for prior authorization.”
Annette Pham, MD, a facial plastic surgeon, otolaryngologist, and partner physician at The Centers for Advanced ENT Care’s Metro ENT and Facial Plastic Surgery division in Rockville, Md., said her surgery coordinator uses a variety of online platforms not tied into the electronic health records, so she needs to keep the usernames and passwords straight. But she said they are helpful.
“Information, including my office visit notes and even photographs, can be uploaded to their systems, which then generate reference numbers for my surgery coordinator to follow up on,” Dr. Pham said. “She can spend less time on the phone trying to answer questions.”
Her office also uses CoverMyMeds for prior authorization for medications, which is also useful, but more so when the pharmacy initiates the authorization.
“If the pharmacy staff doesn’t do it, then I have to enter in all the patient’s data and figure out which form for which medicine and which insurance to choose,” explained Dr. Pham. “The nice thing, though, is that in some instances, I can get approvals within minutes for some medications if I answer correctly.”
Heather Lisa, director of operations at ENT and Allergy Associates, said that using online platforms such as Availity and Navinet has been helpful for the most straightforward requests; she often gets an instant response.
“You hit submit, and you’re going to get that authorization,” she said. Her office has also developed proprietary tools to help assess which payments to collect and from whom, which can help the office’s overall processes.
An Unpredictable Process
This isn’t to say that prior authorization has become simpler over time—otolaryngology practices say that which treatments and medications will require prior authorization is is less predictable than ever and that more kinds of procedures require pre-approval every year. For example, they say they see more and more authorizations needed for septoplasty, turbinate reduction, or sinus intervention when there is clear imaging evidence of sinus disease.
“It’s a moving target because you never know what’s going to be subjected to prior authorization. Things that never needed pre-approval before sometimes all of a sudden pop up,” said Bradford Holland, MD, an otolaryngologist at Waco Ear, Nose & Throat. “It’s just an extreme variable that’s always a time suck for every level of your practice.”
He and other physicians say they need to have peer-to-peer phone calls regarding pre-approvals more than ever—and that unfortunately the peer on the other line often isn’t an otolaryngologist. Sometimes, Dr. Holland said, the call seems pointless, because there’s no information exchanged in the call beyond what was already submitted through paperwork. “You get on a phone call, and they’ll often ask, ‘How’s the patient?’ I’ll say, ‘We mentioned the patient’s condition in the notes; it’s documented right there.’ And they’ll answer, ‘Oh, OK; well, we’ll approve it then.’”
For the last 18 months, the practice has had someone whose full-time job is getting insurance prior approvals. Previously, pre-approvals could be handled “piecemeal,” said Dr. Holland, but not anymore. “It’s become such a big deal that we had to have one person fully devoted to the process,” he said.
Across ENT and Allergy’s 56 locations, the practice has 47 surgical coordinators whose jobs include handling prior authorizations, Lisa said. “We have people who just do this all day long,” she said.
Dr. Pham said that she has seen prior authorization be required for more types of cases, from medications to surgeries to straightforward in-office procedures. “It’s on me to try to remember which insurance deems a certain medication as a tier 1 medication that’s automatically approved, and thus will be filled immediately by the pharmacy, versus a tier 2 medication, which may require prior authorization,” she said.
Some insurance plans now even require prior authorization for a simple lingual frenotomy, a procedure often done at birth to address tongue-tie, Dr. Pham said. This can have cascading effects. “It means that the parents and their newborn need to come in for a consultation first, then authorization is obtained for the procedure, and then the patient needs to return for another visit to have the procedure,” she said. “Not only is this time-consuming for the patient and family, but also it delays necessary treatment.”
New Pre-Approval Rules
Insurance pre-approvals have become such a large and confusing feature of physician office and patient interactions with payers that governmental agencies and medical associations have taken notice—and taken action.
Reforming prior authorization is one of the pillars of the American Medical Association’s (AMA) Recovery Plan for America’s Physicians, and the association has been working toward that goal, particularly in terms of prior authorizations in Medicare plans.
In July, the U.S. House of Representatives Ways and Means Committee advanced bipartisan provisions to reform pre-authorizations in Medicare Advantage plans, a move the AMA applauded. “The unfortunate reality is that prior authorization is overused, costly, inefficient, opaque, and responsible for patient care delays and denials that often lead to poor healthcare outcomes,” said Jesse M. Ehrenfeld, MD, MPH, AMA president, in a press release regarding the move. “As a result, we consistently urge Congress to restrict its use in Medicare Advantage.
In July, the AMA responded to he Centers for Medicare & Medicaid Services (CMS)’ Request for Information to Determine Industry Interest and Capabilities for Modernizing and Improving Access to Medicare Fee-for-Service Requirements, supporting thecenter’s initiative overall, but expressing concern that it might signal the agency’s intent to increase the use of pre-authorization in original Medicare fee-for-service plans, negatively affecting patients and physicians.
In December 2022, CMS issued a proposed rule to expand consumer access to health information and improve the prior authorization process for medical items and services. In the proposed rule, CMS requires some payers to use an electronic prior authorization process, to shorten the time frames to respond to prior authorization requests, and to make prior authorization process more transparent, requiring specific reasons when denying requests. In addition, payers must publicly report certain prior authorization metrics and send decisions within 72 hours for expedited requests and seven calendar days for requests. CMS is also requiring data standards to allow data to be exchanged between payers when a patient changes insurance coverage or has concurrent coverage.
The deadline to submit comments was March 13, 2023; as of September, CMS was evaluating the public response for inclusion in a final rule. (You can read the rule in the Federal Register at https://www.federalregister.gov/documents/2022/12/13/2022-26479/medicare-and-medicaid-programs-patient-protection-and-affordable-care-act-advancing-interoperability.)
The Benefits of Electronic Approval Platforms
While electronic platforms can help in many cases, there can be challenges. For example, information submitted can become lost in a way that wouldn’t have happened in a bygone era when medical practices called up their designated insurance contact to get approval for a procedure. Because of computer glitches, a physician practice staff member might think the process of approval has begun when it actually hasn’t. This can cause delays in treatment. “Information is sometimes sent into a black hole,” Hargrove said.
Lisa described a kind of give-and-take to the changes that have happened in the prior authorization process over the years. Although the review process for more complicated approval requests may be more cumbersome than it used to be, the quick approval of simpler cases allows more time to deal with these complications.
“If we’re on hold waiting for approval for one patient for 45 minutes to an hour, we still have all the other patients who we need to get through our system,” she said. “So, using computer platforms definitely helps us with productivity within the offices as well and getting those authorizations a little bit quicker.”
Dr. Holland, who said he does not use electronic platforms for prior authorization, is skeptical of any suggestions made by the insurance industry. “They’re largely the ones putting up these hurdles anyway,” he said. “Prior authorization is purely a burden put in place to discourage consumption.”
David Zeman, ENT and Allergy’s chief strategy officer, said it isn’t all that surprising that insurance companies are requesting prior authorization for more types of procedures.
“As the medical industry overall, and otolaryngology specifically, have evolved and shifted from more cases being done in the hospital to more procedures being done in the office setting, insurance carriers have evolved in pace with that,” he said. “They continue to not have to pay when they don’t need to or want to. And so, they’ll jump to their medical policies to require these approvals for even minor procedures done in the office. That’s challenging whether I’m a physician, in the back office, or a patient, because it causes unnecessary delays and grief.”
But he said it’s in the interest of physicians and practice managers to work with insurance companies as well as they can. “What I find to be important is working as closely as you can with the payer and your counterparts at these carriers to understand the nuances of their medical policy and what they will and will not require authorization for,” he said. “You choose how you want to approach these conversations. Some people like to be firm, and there is a time for being firm, protective, and supportive of your own patients and practice. But at the end of the day, you have to work with these people, and you want to create partnerships that are long-lasting.”
Thomas R. Collins is a freelance medical writer based in Florida.