Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Reimbursement News

86% of Providers Saw Prior Authorization Requirements Increase

Medical practice leaders stated that the number of procedures and prescription drugs requiring prior authorization grew over the past year, MGMA reported.

Most providers experienced more prior authorization requirements in the past year because more procedures and prescriptions required them, MGMA found

Source: Thinkstock

By Jacqueline LaPointe

- Approximately 86 percent of medical practice leaders reported that prior authorization requirements have increased over the past year, a recent MGMA survey of over 1,000 leaders found.

Only 3 percent stated that prior authorization requirements decreased since 2016 and another 11 percent said that they remained the same in the past year.

The number of medical practice leaders seeing a jump in prior authorization requirements is up from last year. A similar MGMA survey from March 2016 revealed that 82 percent of participants experienced an increase in requirements.

About 9 percent in the 2016 survey also said that they did not experience an increase versus about 14 percent this year.

“Health plan demands for prior approval for physician-ordered medical tests, clinical procedures, medications, and medical devices ceaselessly question the judgement of physicians, resulting in less time to treat patients and needlessly driving up administrative costs for medical groups,” stated Halee Fischer-Wright, MD, MMM, FAAP, CMPE, MGMA President and CEO.

The respondents in the most recent survey pointed to an increasing number of procedures needing an authorization as the top reason why they have experienced more prior authorization requirements in the past year.

They also cited a rising number of prescription drugs requiring authorization as a major driver of increased staff time and resources spent on meeting health plan mandates.

In addition, some respondents attributed the increase in prior authorization requirements to third-party companies involved in the health plan’s utilization management procedures. They explained that some third-party companies made “the process more time-consuming, forcing some practices to hire extra staff to keep up with the requests and subsequently affecting patient care and delaying treatments.”

The MGMA survey results build on the findings from a 2016 American Medical Association (AMA) survey that found 75 percent of physicians thought prior authorization burdens were high or extremely high.

As a result, almost 90 percent of AMA survey participants said that prior authorizations sometimes, often, or always delay care access.

Both healthcare industry groups recently advocated for prior authorization reform. MGMA and AMA along with 15 other organizations urged health plans, benefit managers, and other stakeholders to implement 21 prior authorization improvements to improve care continuity, decrease provider burdens, and advance timely decision-making.

The 21 prior authorization improvements included five utilization management tenets. First, the healthcare industry group coalition stated that prior authorizations should demonstrate clinical validity rather than focus solely on healthcare cost reductions.

Second, utilization management programs should promote care continuity. For example, programs should offer a 60-day grace period for prior authorization or step therapy adherence as long as the patient is already on a treatment plan when they enrolled.

Prior authorizations should also be effective for the duration of the treatment period and health plans should acknowledge if prior step therapy efforts under another health plan did not work.

Third, the groups called on health plans to uphold healthcare transparency and fairness in utilization management programs. Providers and patients should be able to view prior authorization requirements and denials by payer to understand how care may be impacted.

Fourth, health plans should use utilization management programs to increase timely care access and administrative efficiency by standardizing prior authorization requirements across the industry. The key to prior authorization standardization is robust electronic adoption, they argued.

However, electronic prior authorization adoption reached just 18 percent among commercial health plans in 2016, the 2016 CAQH Index showed.

Fifth, the coalition pushed for prior authorization exemptions to reduce administrative burdens. Health plans should target providers with high inappropriate resource use rates rather than use a broad approach to utilization management.

“Most importantly, despite the fact that the vast majority of prior authorization requests are ultimately approved, jumping through these administrative hoops can lead directly to delay or disruption in the delivery of care to the patient,” Fischer-Wright stated about the 21 prior authorization improvements.

“Working together, the coalition has developed a landmark set of principles and I anticipate that this effort will translate directly into a reduction in the waste associated with prior authorization requirements,” she added.


Join 30,000 of your peers and get free access to all webcasts and exclusive content

Sign up for our free newsletter:

Our privacy policy

no, thanks

Continue to site...