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Prior auths not improving despite payer promises


Vast majority of medical groups say prior auths continue to increase

The vast majority (79%) of medical groups polled by the Medical Group Management Association indicated the number of prior authorization requirements rose in the past 12 months. Only 2% indicated the requirements decreased, and 19% said they remained the same.

Since 2016, MGMA members have reported that they experienced an increase in prior auths over the prior year. Consider the following:

  • 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 in September of 2019, found 90% of healthcare leaders reporting PA requirements on the rise compared to the previous year.

The challenges created by prior auths listed by MGMA members include a lack of response or slow response from payers for approvals, increase time spent by staff to secure prior authorizations, a lack of automation in payers’ prior auth processes, and delays in patient care due to lack of prior authorization.

There is some hope that Congress will take action to curb payers’ prior authorizations. Legislation has been reintroduced that would limit Medicare Advantage plan prior auth requirements. The Improving Seniors’ Timely Access to Care Act (S. 3018/H.R. 3173) would increase transparency around Medicare Advantage 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 program. Since this bill was drafted using a set of principles agreed upon by plans and providers in 2018, MGMA says it hopes to see it passed into law before the end of the year.

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