Payer prior authorization requirements on physicians continue rapid escalation: increasing practice overhead and delaying patient care

MGMA Stat - May 16, 2017

Data Stories

MGMA Stat - Prior Authorization Requirements - 3.29.16

Medical practice leaders say that the burden of submitting prior authorization requests and supporting documentation to health plans is getting worse.

A May 16 MGMA Stat poll found 86% of respondents saying that prior authorization requests have increased in the past year, while 3% report those requests decreasing and another 11% saying they’ve stayed the same in the past year.

Agreements between health plans and their participating physicians routinely include a statement that the insurer has the right to determine the medical necessity of surgery, imaging studies, medication and many other procedures. Physician practices then devote clinical and administrative staff time and resources to submit preauthorization requests for each service, increasing overhead and often delaying patient care.

“Health plan demands for prior approval for physician-ordered medical tests, clinical procedures, medications, and medical devices ceaselessly question the judgement of physicians, resulting in less time to treat patients and needlessly driving up administrative costs for medical groups,” said Halee Fischer-Wright, MD, MMM, FAAP, CMPE, MGMA President and CEO.

MGMA Stat poll respondents who said they’ve seen an increase cited an increase in the number of procedures requiring authorization than in previous years, as well as the number of medication prescriptions also requiring increased staff time and resources toward meeting health plan demands. Some respondents blamed the use of third-party companies who handle authorizations for making the process more time consuming, forcing some practices to hire extra staff to keep up with the requests and subsequently affecting patient care and delaying treatments.

MGMA has partnered with the American Medical Association (AMA), American Academy of Family Physicians (AAFP), American College of Cardiology (ACC), American Hospital Association (AHA) and other organizations earlier this year to develop and implement a set of 21 principles aimed to reduce the administrative burden posed by preauthorization requests to physician practices and their patients, the latter of whom may face a delay in the start of necessary tests or treatment, with adverse patient health outcomes as a possible end result.

A similar MGMA Stat poll from March 29, 2016, found 82% of respondents reporting an increase in prior authorization requirements from health plans, with about 9% saying they saw no increase at that time. 

The May 16 poll had 1,041 applicable responses out of 1,095 total responses.


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