Prior Authorization Requirements in Medicare Advantage Have Gone Up, Not Down

Surveyed medical groups reveal burdens have increased in the past 12 months, resulting in delays or denials for necessary care.

Despite scrutiny of prior authorization practices in Medicare Advantage (MA), requirements for the administrative process have only grown over the past year, according to a survey by the Medical Group Management Association (MGMA).

With MA continuing to experience a significant rise in enrollment, MGMA surveyed 601 medical groups to better understand the impact of prior authorization in the program.

More than four out of five respondents (84%) said prior authorization requirements for MA have increased in the past 12 months, with less than 1% reporting requirements had decreased.

Practices ranked MA as the most burdensome program when it comes to obtaining prior authorization (46%), ahead of commercial plans (32%), Medicaid (20%), and traditional Medicare (4%).

Prior authorization in MA is becoming a greater issue due to more and more beneficiaries choosing the program. The survey found that 58% of practices saw 15% or more their patients either switch from traditional Medicare to MA or between MA plans, while 84% of respondents said they had to reauthorize existing Medicare-covered services for those Medicare enrollees who've switched plans.

"With half of all Medicare beneficiaries enrolled in private Medicare Advantage (MA) plans, prior authorization reform has taken on new urgency at the federal level," Anders Gilberg, senior vice president of Government Affairs at MGMA, said in a statement. "Medical groups now identify prior authorization in the MA program as more burdensome than commercial insurance and Medicaid. More needs to be done to protect beneficiaries."

Prior authorization requirements are having unintended consequences such as delaying and denying necessary care, increasing practice costs, and disrupting provider workflows.

Nearly all medical groups surveyed (97%) said their patients experienced delays or denials for necessary care due to the administrative process, with requirements varying widely across payers. More than nine in 10 respondents (91%) agreed that a single standard electronic prior authorization system across all insurers would alleviate burden on their practice, while just 7% said MA plans they're contracted with offer a gold-carding program.

With providers facing significant financial pressure in the wake of COVID-19, prior authorization is only adding to practice costs. Over three-quarter (77%) of respondents said they have hired or redistributed staff to work on prior authorizations due to an increase in requests, and 60% said there are at least three different employees involved in completing a single prior authorization request.

Even when practices have enough of a workforce and adequate resources to devote to prior authorization, requirements often mean spending plenty of time and energy on requests instead of caring for patients. More than a third of practices reported spending upwards of 35 minutes on an average single prior authorization request, with nearly 5% spending 91 minutes or more.

CMS' MA final rule aims to tackle these issues by streamlining prior authorization, including requiring approvals to remain valid for as long as medically necessary and offering coordinated care plan protection for patients. The rule has received widespread support from medical groups like MGMA, along with payer groups.

"MGMA supports commonsense policies that alleviate onerous administrative requirements and improve the timeliness of clinical care delivery," Gilberg said. "Efforts to streamline, standardize, and ultimately reduce the volume of prior authorization demands on medical practices such as CMS' proposed Prior Authorization and Interoperability Rule, and the Improving Seniors' Timely Access to Care Act in Congress, will further strengthen and modernize the MA program."