For frontline medical group practices navigating the COVID-19 pandemic, there’s been virtually no relief in sight when it comes to payer prior authorization (PA) requirements since 2020.
The Medical Group Management Association’s most recent MGMA Stat poll asked medical groups: “How did payer prior authorization requirements change since 2020?” The vast majority (81%) answered “increased,” 17% responded “stayed the same,” and only 2% remarked they “decreased.”
This poll was conducted on May 18, 2021, with 716 applicable responses.
Some healthcare leaders who reported PA requirements growing in the past year said they’ve had to add full-time position(s) to handle prior auth work due to several factors, including:
- Training for several variations/inconsistencies across payers on PA requirements
- Frequent updates in payer requirements (e.g., site of service updates)
- Understanding vague or opaque requirements, especially regarding step therapy
- Increasing rates of claim denials and requirements for peer-to-peer reviews
- Slow responses from payers for approvals, including lengthy holds for phone calls.
These factors are compounded by a tightening labor market, in which numerous workers consider leaving the profession and a sizable majority (88%) of healthcare leaders report having difficulty recruiting medical assistants (according to a May 4 MGMA Stat poll).
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:
- A 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 (on Sept. 17, 2019), found 90% of healthcare leaders reporting PA requirements on the rise compared to the previous year.
Medical groups faced unprecedented challenges stemming from the COVID-19 pandemic last year. Through #MGMAAdvocacy, we fought to keep group practices solvent and able to continue treating patients. Unfortunately, these poll results indicate that as practices struggled to keep their doors open, health plans continued to obstruct delivery of timely patient care.
Last Congress, MGMA supported and helped draft the Improving Seniors’ Timely Access to Care Act, which would put guardrails on Medicare Advantage (MA) plan PA requirements. More specifically, the bill would increase transparency around MA prior authorization requirements, standardize the PA process for routinely approved services, and establish an electronic PA program. Although not passed last Congress, this bill had immense support, including 280 cosponsors, a Senate companion bill, and endorsement from almost 400 organizations. Last week, the House reintroduced this legislation, and MGMA Government Affairs expect the Senate to reintroduce the bill soon. MGMA supports this bill and encourages MGMA members to reach out to their congressional representatives to voice support as well.
Last year, the Centers for Medicare & Medicaid Services (CMS) published a proposed rule that would streamline processes related to PA. Unfortunately, the rule would only place requirements on Medicaid and CHIP managed care plans, state Medicaid and CHIP fee-for-service programs, and Qualified Health Plans (QHP) issuers on the Federally-facilitated Exchanges (FFEs) — MA plans were left out. Right before President Biden took office, CMS finalized the rule and posted it online; however, it was never published in the Federal Register. It now is in limbo under the White House’s Regulatory Freeze. MGMA has advocated for the inclusion of MA plans in this rule and is waiting on CMS to act.
- MGMA’s Position Paper on Prior Authorization
- If you have any questions or reactions to final policies, please reach out to MGMA Government Affairs at firstname.lastname@example.org.
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