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.’”
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November 2023For 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.