Data Insights

Prior authorization pains growing for 9/10 physician practices

MGMA Stat

Federal Compliance

Claire Mansbach JD
The Medical Group Management Association’s most recent MGMA Stat poll asked healthcare leaders: How did payer prior authorization requirements change in 2019? The vast majority (90%) answered  “increased,” 9% responded “stayed the same” and only 1% remarked they “decreased.”
 
This poll was conducted on September 17, 2019, with 999 applicable responses.
 
For years, payers have required practitioners to obtain prior authorization (PA) before providing certain medical services and prescription drugs to patients. This health plan cost-control process often delays care unnecessarily at the expense of the patient’s health and the practice’s resources. Practices continue to face mounting challenges with PA, including issues submitting documentation manually via fax or through the health plan’s proprietary web portal, as well as changing medical necessity requirements and appeals processes to meet each health plan’s requirements.

Member feedback

PA continues to present growing challenges for physician practices. For the last three years, MGMA members reported seeing an increase in PA requirements. A Sept. 17 MGMA Stat poll reflects that trend, with 90% of respondents indicating that they saw an increase in PA requirements from payers in 2019. In 2017 and 2018, similar MGMA Stat polls resulted in 86% of respondents reporting increased PA requirements, both of which were higher than a 2016 poll, wherein 82% of respondents reported an increase.

What is MGMA doing to reduce PA burden?

Since PA requirements are disruptive and burdensome for physician practices and patients, MGMA is advocating for industry-wide solutions, including:
  • Reducing the overall volume of prior authorizations on medical services and drugs
  • Waiving PA requirements for clinicians in risk-based contracts or alternative payment models, which are inherently designed to facilitate cost-effective care delivery and appropriate utilization
  • Requiring transparency of payer PA policy and establishing evidence-based clinical guidelines available at the point of care
  • Increasing the automation and efficiency of PA requirements through adoption of industry-developed electronic standards and operating rules
MGMA advocates for PA burden relief at the congressional level. With a renewed interest in healthcare this year, members of Congress introduced legislation that aims to put common sense parameters around PA by requiring Medicare Advantage plans to support electronic PA, make real-time PA decisions, clarify which services require PA and establish an exemption for peroperative services.
The impetus of this bill came from a consensus statement signed by both the provider and payer communities, which outlined five different areas in which PA programs could be improved and meaningful reform achieved. If you are interested in supporting this important legislation, use MGMA’s Contact Congress portal to send a letter to your congressional representative. If codified into law, this legislation would be a monumental step towards combatting the challenges associated with PA.  

Additional resources

 
Would you like to join our polling panel to voice your opinion on important practice management topics? MGMA Stat is a national poll that addresses practice management issues, the impact of new legislation and related topics. Participation is open to all healthcare leaders. Results of other polls and information on how to participate in MGMA Stat are available at: mgma.com/stat.

About the Author

Claire Mansbach
Claire Mansbach JD
Associate Director MGMA
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