MGMA: Medicare Advantage Growth Exacerbates Prior Authorization Burdens

As Medicare Advantage enrollment grows, medical practices are experiencing more prior authorization burdens, including higher administration costs and disrupted workflows, a report from the Medical Group Management Association (MGMA) found.

MGMA surveyed over 600 medical groups in March 2023 to further understand the impact of prior authorization in the Medicare Advantage program.

The majority of practices (95 percent) provide care to patients covered by Medicare Advantage, and 75 percent report they are seeing an increasing number of these patients. Compared to commercial plans, traditional Medicare, and Medicaid, practices said Medicare Advantage was the most burdensome when it came to obtaining prior authorization.

Nearly 85 percent of respondents said that prior authorization requirements for Medicare Advantage have increased in the last 12 months, compared to less than 1 percent who reported a decrease.

Almost 6 in 10 practices saw 15 percent or more of their patients either switch from traditional Medicare to Medicare Advantage or between Medicare Advantage plans. This led to 84 percent of practices having to reauthorize existing services covered by Medicare for those beneficiaries who switched plans.

Prior authorization has historically disrupted workflows for medical groups and diverted time away from delivering patient care.

Thirty-five percent of medical groups said they spend upwards of 35 minutes on an average prior authorization request. Nearly 5 percent reported spending 91 minutes or more on a single request.

Most respondents said insurers required them to utilize a health plan proprietary web portal (91 percent), fax machine (90 percent), or an electronic portal (85 percent) to submit prior authorizations. Three in ten practices reported having to interface with 11 or more health plan proprietary web portals, while 76 percent had to interface with five or more portals.

Not only is prior authorization creating burdensome tasks, but it is also increasing practice costs.

Sixty percent of respondents said at least three employees are involved in completing a prior authorization request. Additionally, 77 percent of practices said they have hired or redistributed staff to work on prior authorization to the increase in requests.

While medical practices are investing their resources in additional staff to manage prior authorization requests, they are also facing high inflation, clinical staffing shortages, and other cost increases.

“Reducing prior authorization requirements that do not improve patient care will assist group practices in focusing on patients and allow them to invest resources in initiatives that improve healthcare delivery, further clinical priorities, and reduce costs,” the report stated.

Almost all respondents (97 percent) reported that their patients experience delays or denials for medically necessary care due to prior authorization requirements.

Further, 72 percent of practices said that in cases requiring a peer-to-peer discussion between a practice clinician and a health plan clinician, the health plan clinician was generally not from a specialty relating to the treatment or disease in question.

Ninety-three percent of respondents noted that the Medicare Advantage plans they contract with do not offer a gold-carding program. Gold carding is when plans exclude providers from prior authorization requirements if they have high approval histories.  

More than 90 percent of practices said having a single standard electronic prior authorization system across all insurers would help alleviate some of the burdens stemming from the process.

Medicare Advantage enrollment is expected to continue growing, generating concern among provider groups.

MGMA has committed to working with CMS to finalize prior authorization reforms in Medicare Advantage, including the Prior Authorization and Interoperability proposed rule, which would establish an electronic prior authorization program. The organization also supported CMS’ finalization of the Medicare Advantage and Part D rule, which included changes to streamline the prior authorization process.

MGMA also plans to work with Congress to pass the Improving Seniors’ Timely Access to Care Act and collaborate with stakeholders and policymakers to address other aspects of prior authorization.