Prior authorization burdens are increasing

Healthcare leaders agree prior authorization burdens are increasing.

That is according to the latest data from the Medical Group Management Association (MGMA), which recently conducted a survey about prior authorization to medical groups. Prior authorization requires medical groups to get authorization from health insurers and payors that a healthcare service, treatment, medical device or prescription drug is medically necessary and covered. 

A whopping 4 out of 5 (79%) respondents agreed that prior authorization requirements have increased over the last 12 months. Another 19% said the requirements stayed the same, while just 2% said they decreased. The findings align with previous trends found by MGMA, with medical professionals consistently reporting requirements increasing since 2016.

Prior the pandemic, 90% of healthcare leaders reported prior authorization requirements were increasing, according to a 2019 MGMA poll.

Physician groups argue these requirements can be burdensome, diverting resources that could be used with patients and potentially leading to worse patient outcomes. The top complaints about the requirements include:

  • A lack of response or slow response from payers for approvals
  • Increased time spent by practice staff working to secure prior authorizations, worsened by staffing shortages
  • A lack of automation in payers’ prior authorization processes
  • Delays in patient care due to lack of prior authorization

“These onerous prior authorization requirements present medical groups with a variety of obstacles — including issues submitting documentation through non-standardized health plan web portals, as well as constantly changing medical necessity requirements and appeals processes — and often result in dangerous delays to patient care and unnecessary increases in administrative overhead,” Andrew Gillberg, senior vice president of government affairs at MGMA, said in a statement.

The association has previously advocated for prior authorization requirements to decrease to reduce burdens on medical groups. New legislation in Congress, called the Improving Seniors’ Timely Access to Care Act, would do just that with guardrails on Medicare Advantage (MA) plan prior authorization requirements, according to MGMA. The bill would increase transparency around the 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.

“MGMA is once again calling on Congress to pass legislation that would reduce the overall volume and burden of prior authorization requirements, allowing medical groups to focus on delivering high-quality care to the patients they serve,” Gillberg said.

MGMA is not the only medical association advocating for standardization of prior authorization –– other groups such as the American Academy of Family Physicians (AAFP) and the American Medical Association (AMA) are also pushing for it.

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Amy Baxter

Amy joined TriMed Media as a Senior Writer for HealthExec after covering home care for three years. When not writing about all things healthcare, she fulfills her lifelong dream of becoming a pirate by sailing in regattas and enjoying rum. Fun fact: she sailed 333 miles across Lake Michigan in the Chicago Yacht Club "Race to Mackinac."

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