Earlier this year, the Medical Group Management Association (MGMA) reported that 81% of medical groups experienced an increase in prior authorization requirements since 2020 – with only 2% reporting a decrease (the other 17% reported prior authorization requirements stayed the same).
Some of the 716 respondents to the poll conducted on May 18, 2021, reported that they even had to hire new full-time positions to handle the prior authorization increase. Some of the reasons provided for needing a new hire included: training for several variations/inconsistencies across payers on PA requirements; frequent updates in payer requirements (site of service updates); understanding vague or opaque requirements, especially with respect to step therapy; increasing rates of claim denials and requirements for peer-to-peer reviews; and slow responses from payers for approvals, including long hold times for phone calls.
According to MGMA, prior authorizations have been increasing for years, with an increase in prior authorization requirements over the prior year happening annually since 2016. In March 2016, a MGMA Stat poll reported 82% of health care leaders had an increase in prior authorization requirements from payers and by May 2017, that percentage grew to 86%. The most recent poll (prior to the COVID-19 pandemic) was conducted in September 2019 and found that 90% of health care leaders reported prior authorization requirements had increased from the previous year.
According to MGMA, prior authorizations obstruct the delivery of timely patient care and medical groups are continuing to face “unprecedented challenges stemming from the COVID-19 pandemic.”
“Despite a modest reprieve from certain health plan prior authorization requirements during the first few months of the pandemic, medical groups report a significant spike in prior authorization requirements since 2020,” said Anders Gilberg, MGMA SVP of Government Affairs. “In addition to the sharp rise in prior authorization demands, practices report increased denials, delayed approvals for care, and constantly changing rules.”
Perhaps we will see legislative change happen surrounding prior authorizations, as the United States House of Representatives recently reintroduced the Improving Seniors’ Timely Access to Care Act, which would require Medicare Advantage plans to adopt electronic prior authorization, in addition to several other reforms aimed at streamlining the process. Lawmakers behind the legislation are hoping for bipartisan support to quickly pass the House legislation and a Senate companion bill.