Prior authorizations not improving despite payer’s promises


The vast majority (79%) of medical groups surveyed by the Medical Group Management Association indicated that the number of prior authorization requirements had increased over the past 12 months. Only 2% said the requirements had decreased and 19% said they had stayed the same.

Since 2016, MGMA members have reported experiencing an increase in prior clearances compared to the previous year. Consider the following:

  • This percentage increased to 86% in a similar MGMA Statistical survey of May 16, 2017.
  • The most recent survey conducted before the COVID-19 pandemic in September 2019 found that 90% of health officials reported an increase in PA requirements from the previous year.

Challenges created by pre-authorizations listed by MGMA members include a lack of response or slow response from payers for approvals, increased staff time spent obtaining pre-authorizations, a lack of automation in pre-authorization processes for payers and delays in patient care due to lack of pre-authorization.

It is hoped that Congress will take action to limit payor pre-authorizations. Legislation has been reintroduced that would limit the pre-authorization requirements of the Medicare Advantage plan. the An Act to improve rapid access to care for seniors (S. 3018/HR 3173) would increase transparency around Medicare Advantage pre-authorization requirements, standardize the process for regularly approved services, ensure claims are reviewed by qualified medical personnel, and establish an electronic authorization program prior. As this bill was drafted using a set of principles agreed by plans and providers in 2018, the MGMA hopes to see it passed before the end of the year.

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