Medical Group Management Association
Join Now
Now available! Access your Continuing Education all from one platform! Explore the new portal by clicking “Manage Education Credits” or “My Dashboard" under My Account.

Virtually all medical groups say payer prior authorization requirements aren’t improving

MGMA Stat - March 2, 2022

Medicare Payment Policies

Reimbursement

Claire Ernst JD
For medical groups navigating their recovery from the impacts of the COVID-19 pandemic, there’s one thing nearly all of them have in common: Payer prior authorization requirements have not eased up in the past year.



A March 1, 2022, MGMA Stat poll asked medical groups: “How did payer prior authorization requirements change in the past 12 months?” The vast majority (79%) answered “increased,” 19% responded “stayed the same,” and only 2% remarked they “decreased.”

The poll had 644 applicable responses.

Member feedback

Prior authorization (PA), a utilization management tool used by health plans to control costs, has been on the rise for years. Since 2016, MGMA members have reported that they experienced an increase in PA requirements over the prior year:
  • March 29, 2016, MGMA Stat poll found 82% of healthcare leaders reported an increase in PA requirements from payers.
  • That percentage grew to 86% in a similar MGMA Stat poll from May 16, 2017.
  • The most recent poll conducted prior to the COVID-19 pandemic (Sept. 17, 2019), found 90% of healthcare leaders reporting PA requirements on the rise compared to the previous year.

Notably, MGMA members reported the following as their most significant challenges associated with rising prior authorization requirements:
  • Lack of response or slow response from payers for approvals
  • Increased time spent by practice staff working to secure prior authorizations, which has been compounded by staffing shortages amid a tightened labor market and intense competition for workers
  • A lack of automation in payers’ PA processes
  • Delays in patient care due to lack of PA

#MGMAAdvocacy

Legislation reintroduced this Congress would put guardrails on Medicare Advantage (MA) plan prior authorization requirements. More specifically, the Improving Seniors’ Timely Access to Care Act (S. 3018/H.R. 3173) would increase transparency around MA prior authorization requirements, standardize the process for routinely approved services, ensure that requests are reviewed by qualified medical personnel, and establish an electronic prior authorization (ePA) program. Since this bill was drafted using a set of principles agreed upon by plans and providers in 2018, we hope to see it passed into law before the end of the year. To help #MGMAAdvocacy efforts, you can reach out to your congressional representatives to voice support as well.

Additional resources

JOIN MGMA STAT
Our ability at MGMA to provide great resources, education and advocacy depends on a strong feedback loop with healthcare leaders. To be part of this effort, sign up for MGMA Stat and make your voice heard in our weekly polls. Sign up by texting “STAT” to 33550 or visit mgma.com/stat. Polls will be sent to your phone via text message.
 

About the Author

Claire Ernst
Claire Ernst JD
Director, Government Affairs MGMA
X

Shopping Cart

Your cart is empty

Subtotal:
Click here if your organization is tax exempt
X

A State Sales tax exempt certificate must be on file and taxable items cannot be ordered online. For immediate assistance during normal business hours of 7:00am to 5:00pm MT M-Th and 7:00 am to Noon MT on Friday, please call toll-free: 877-275-6462, ext. 1888

X

Checkout

Use two letter code for US states
Use three letter code for country
Use two letter code for US states
Use three letter code for country
Use two letter code for US states
Use three letter code for country

Grand Total:
Saved credit card is required for opt-in to autorenew.

Questions? Contact the MGMA Service Center for assistance during checkout or review our return policy for more information.
X

Confirmation

,
,

Total:
Payment:
Balance:
 

Thank you for your purchase! If you purchased an event, you will be receiving a follow-up email from our Learning Management System regarding the product/event purchased and no further action is required.


Loading...