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.
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 (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
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.
- MGMA’s Position Paper on Prior Authorization
- MGMA’s Annual Regulatory Burden Report (October 2021)
- MGMA’s Grassroots Letter on Prior Authorization Reform
- The Improving Seniors’ Timely Access to Care Act of 2021 resources
- 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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