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As Medicare Advantage plans surge in popularity, critics say authorization demands are rising, too


Most medical groups say the requirements have increased over the past year. Providers have been pressing the Biden administration and lawmakers for reforms.

The MGMA says 84% of its members report prior authorization demands in Medicare Advantage plans rose in the past year. (Image credit: ©Freedomz - stock.adobe.com)

The MGMA says 84% of its members report prior authorization demands in Medicare Advantage plans rose in the past year. (Image credit: ©Freedomz - stock.adobe.com)

Most medical groups say the prior authorization requirements in Medicare Advantage programs are becoming more onerous, even as more seniors are signing up for the plans.

In fact, 84% of medical groups said prior authorization demands in Medicare Advantage plans have increased over the past 12 months, according to a new report by the Medical Group Management Association.

Only 1% of the medical groups surveyed said prior authorization demands decreased in the past year. The MGMA surveyed more than 600 medical groups in its survey.

“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, the MGMA’s senior vice president of government affairs, 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.”

Most medical groups, hospitals and physicians seethe over the process of prior authorization, which involves getting payers to sign off on medications, treatments and procedures. Insurance groups argue that prior authorization plays a vital role in controlling costs and avoiding unnecessary medical treatments and procedures.

However, the American Medical Association and a host of other healthcare advocates argue that prior authorization interferes with patient care, delaying some treatments and at times leading to negative outcomes. In some cases, patients abandon treatment plans after enduring delays in getting authorization, the AMA says.

In the MGMA survey, 97% of respondents said the prior authorization process is delaying medically necessary care.

Medical groups and physicians say they routinely have to make the case for treatment to health plan clinicians that practice in other areas. Nearly three quarters (72%) of the respondents said that when they must participate in peer-to-peer conversations in authorization requests, the clinician is not involved in a specialty relevant to the treatment, the MGMA survey found.

The AMA and others say the time-consuming process of prior authorization plays a leading role in physician burnout. In the MGMA survey, more than a third (35%) of respondents say they spend more than 35 minutes on an average authorization request.

Critics have derided the authorization requirements of Medicare Advantage programs, which have gained increasing popularity.

More than 30 million Americans are now enrolled in Medicare Advantage plans, the Centers for Medicare & Medicaid Services reported in January. More than half of all eligible Medicare beneficiaries have enrolled in those plans, the Kaiser Family Foundation reported this week. Insurers cite the growth of the programs as a testament to their value, saying they offer more coverage for seniors at little cost.

The CMS proposed a new rule in December that would revamp prior authorization in Medicare Advantage plans, and providers have said the proposal would make some much-needed improvements. The rule would require some insurers to respond to prior authorization requests more quickly, and to make requests more transparent. Some payers would have to move to electronic authorization by 2026.

The AMA and more than 100 medical societies wrote a joint letter to CMS Administrator Chiquita Brooks-LaSure urging the agency to finalize reforms to the Medicare Advantage plans.

Lawmakers have been applying more scrutiny to the prior authorization demands of Medicare Advantage plans. The House of Representatives approved legislation to streamline the authorization process last year, but the Senate couldn’t pass the bill before the congressional session ended. Many of those provisions are now in the administration’s reform plans.

Still, healthcare advocates have said they’d like to see Congress enact measures to reform the prior authorization process, and they have noted Democrats and Republicans have called for change.

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