Prior Authorizations, Quality Payment Program Burden Practices

Prior authorizations

Medical group practice leaders ranked prior authorization as the most burdensome regulatory issue in 2019.

Eighty-three percent of respondents reported being very or extremely burdened by the utilization management technique used by payers to control costs and unnecessary care. That percentage is up slightly from 82 percent of respondents in last year’s annual regulatory burden report.

Respondents in 2019 reported a growing number of issues related to submitting documentation manually via fax or through the health plan’s proprietary web portal and changing medical necessity requirements and appeal processes, which can differ by health plan.

One respondent even said that his or her practice hired three new employees to manage just the prior authorization requirements for their plans.

Prior authorizations have recently become a major issue for healthcare providers. The American Medical Association (AMA) also recently found that 88 percent of practicing physicians think prior authorization burdens have increased over the last five years.

Council for Affordable Quality Healthcare, Inc. (CAQH) also reported earlier this year that 88 percent of prior authorizations are done manually, resulting in care delays.

Efforts are underway to automate the process to reduce the burden of prior authorizations, CAQH stated. However, challenges remain and health payers are not necessarily making prior authorization reform a priority, AMA reported.

Quality Payment Program

Medicare’s Quality Payment Program was the second most burdensome regulatory issue according to medical group practice leaders. Although, fewer respondents in 2019 thought the value-based care program was very or extremely burdensome compared to the previous year.

In this year’s survey, 77 percent of respondents felt the Quality Payment Program and its two tracks – the Merit-Based Payment Incentive System (MIPS) and Advanced Alternative Payment Model (APM) – were very or extremely burdensome.

The program topped the list of regulatory burdens last year, with 80 percent of respondents saying it was more than moderately burdensome.

Respondents in 2019 were particularly burdened by MIPS, the report uncovered.

About 81 percent of respondents said they participate in MIPS, a mandatory value-based care program for certain Medicare clinicians. And of these respondents, 87 percent said they feel that positive payment adjustments through MIPS do not cover the costs of time and resources spent preparing for and reporting under the program.

Medical group practice leaders also experienced problems with quality reporting under MIPS. Half of respondents said they were dissatisfied with the availability of applicable MIPS quality measures, and slightly more (58 percent) said they were particularly dissatisfied with MIPS cost measures, which are being phased into the program.

The report found that medical group practice leaders are not receiving the feedback they need to succeed under MIPS.

Seventy-six percent of respondents said CMS’ feedback on MIPS quality measure performance was not actionable for improving clinical outcomes. That percentage increased to 77 percent when respondents were asked how actionable CMS’ feedback on MIPS cost measure performance was for reducing costs.

“Value based reforms have tremendous promise to support physicians who provide high quality, low cost care,” stated Gilberg. “However, in order to be successful, the government needs to provide medical groups with clinically relevant and actionable patient data. As evidenced by this survey, there’s still much work to be done.”

Other regulatory burdens ranked as very or extremely burdensome by more than half of respondents in 2019 included audits and appeals, lack of EHR interoperability, Medicare Advantage chart audits, and translation and interpretation requirements.