Spotlight: Prior Authorization in Medicare Advantage

Following substantial growth of enrollment in Medicare Advantage (MA) plans during the previous two decades, in April 2022, the Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS) published a report which detailed how MA beneficiaries' care was often negatively impacted as a result of delayed and denied prior authorization requests, despite the requests meeting Medicare coverage rules.

To further understand the critical impact of prior authorization within the MA program, and to allow us to better educate Congress and the Administration about obstacles to delivering high-quality patient care to beneficiaries, in March of 2023, MGMA surveyed over 600 medical groups. Findings overwhelmingly show that prior authorization in MA is increasingly burdensome for medical group practices and contributes to:

• Increased practice administration costs;
• Disrupted practice workflow; and,
• Delays and denials of necessary medical care.

There is still much to be done at the federal level to provide regulatory relief for medical groups and alleviate barriers to patient care. MGMA will continue to play a key role in prior authorization policy discussions with policymakers to ensure that medical practices have a voice in Washington.

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