Dive Brief:

  • Among 644 medical practices in a new poll, 79% said insurers’ prior authorization requirements had risen over the past year, according to the Medical Group Management Association. That’s down from 90% that said prior authorization demands were increasing in the association’s pre-pandemic survey conducted in September 2019.
  • Even so, another 19% of practices in the latest poll, conducted March 1, reported prior authorization requirements stayed the same in the past year, indicating the burdensome issue for doctors is not improving. Just 2% of medical practices said prior authorization obligations decreased in the past year, the MGMA Stat poll found.
  • The requirements are a major headache for medical groups. MGMA members surveyed in October rated prior authorization the top regulatory challenge they face, with 88% calling it “very” or “extremely” burdensome.

Dive Insight:

Health plans have been expanding the use of prior authorization as a tool to control costs for several years, to the frustration of physicians. MGMA members put the practice at the top of a list of burdensome issues that include COVID-19 workplace mandates, audits and lack of electronic health record interoperability, among other challenges.

The administrative hurdles require medical practices to obtain authorization before providing treatments, tests or prescription drugs to patients. Physicians say the requirements not only delay patient care but also raise provider costs, by increasing time spent by staff to secure authorizations. Those challenges have been compounded during the pandemic by staffing shortages and intense competition for workers in the tightened labor market, MGMA said.

Practices also report struggling with submitting documentation via fax or through a health plan’s web portal, changing medical necessity requirements and appeals processes, and having to make multiple attempts to get patients the care they need, according to MGMA.

The group said its members have been contending with escalating prior authorization requirements since 2016. That year, 82% of healthcare leaders polled reported an increase in the requirements from payers, with the percentage growing to 86% in a 2017 survey and 90% in 2019.

The American Medical Association has made reducing prior authorization burdens a key priority of its advocacy efforts this year. The AMA believes that medically necessary clinical services and prescriptions covered by health insurance plans should be administered without delay, the group said in materials published in conjunction with a webinar on advocacy held last month.

“Prior authorization undermines physicians’ medical expertise and leads to considerable delays in patient care,” the AMA said.

A 2021 AMA survey found 93% of physicians reported care delays associated with prior authorization, and 82% said the requirements can sometimes cause patients to abandon treatment. The process is a contributing factor to physician burnout, the AMA said.

In the worst case scenario, failure to administer medically necessary care can lead to poor health care outcomes, the group cautioned. “Most startlingly, 34% of AMA survey participants reported that prior authorization led to a serious adverse event, such as hospitalization, disability and permanent bodily damage, or death, for a patient in their care,” the AMA said.

The AMA’s survey found physicians complete an average of 41 prior authorizations per week, and 40% of respondents said they hired staff to work exclusively on prior authorization requirements.

Both the AMA and MGMA said they support legislation introduced in Congress that would increase transparency on Medicare Advantage prior authorization requirements, standardize processes for routine services and establish an electronic program for submitting documentation.