'Burdensome' Medicare Advantage prior authorization requirements cause delays or denials at 97% of practices
Increased enrollment in Medicare Advantage plans is not without its woes for both patients and providers, as a new report details how problematic prior authorization policies are negatively impacting patient care and medical practices.
In March of 2023, the Medical Group Management Association (MGMA) surveyed more than 600 medical groups to better understand the impact of prior authorization (PA) requirements within Medicare Advantage (MA) plans. The responses revealed that 84% of practices have seen an increase in prior authorization requirements within MA over the last 12 months, but the ominous revelations didn't end there
While this figure is problematic in itself, the report also shines a light on a multitude of negative impacts this increase has caused across the board. The report also revealed that:
The increase in PA requirements was accompanied by 15% of patients switching plans in 58% of the practices.
84% have had to reauthorize existing Medicare-covered services for patients who switched to MA plans.
35% spend 35 minutes or more on a single PA request, while it takes up to 91 minutes for 5% of the surveyed practices.
30% of practices have to interact with 11 or more health plan portals to acquire PA and 5% interface with five or more portals.
It takes the involvement of at least three different employees to complete a single PA at 68% of practices.
77% have hired additional staff or redistributed duties as a result of increased PA requests.
97% of the groups reported patients were faced with delays or denials of medically necessary care due to PA requirements.
As a result, these practices, many, which are already short staffed, are burdened with increased costs, and patients are faced with the possibility of going without critically needed (and medically justified) care in the form of delayed exams and prescription denials.
Anders Gilberg, MGMA’s senior vice president of government affairs, noted that half of all Medicare beneficiaries are enrolled in a private MA plan, which makes the issue of burdensome PA requirements (and the consequences that accompany them) something that warrants heightened attention on a federal level.
“More needs to be done to protect beneficiaries. MGMA supports commonsense policies that alleviate onerous administrative requirements and improve the timeliness of clinical care delivery,” Gilberg said in a statement. “Efforts to streamline, standardize, and ultimately reduce the volume of prior authorization demands on medical practices such as CMS’ proposed Prior Authorization and Interoperability Rule, and the Improving Seniors’ Timely Access to Care Act in Congress, will further strengthen and modernize the MA program.”
The full report can be viewed here.
In addition to her background in journalism, Hannah also has patient-facing experience in clinical settings, having spent more than 12 years working as a registered rad tech. She began covering the medical imaging industry for Innovate Healthcare in 2021.