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Prior authorization and regulations hindering delivery of care, say providers

by John R. Fischer, Senior Reporter | November 08, 2021
Prior authorization and regulations are making it harder to allocate resources for care of patients, say providers
Federal regulations are straining healthcare providers’ ability to offer quality care to patients.

That’s what the majority of 420 medical group practices told the Medical Group Management Association for its 2021 Annual Regulatory Burden Report. And while 95% say that a reduction in regulatory burdens would allow them to reallocate resources better, 91% have only seen these regulations increase over the past 12 months.

The burden that ranked highest was prior authorization requirements within Medicare’s Quality Payment Program, followed by COVID-19 workplace mandates. "In the current environment medical groups are grappling with unprecedented staff shortages and finite resources. Physician and nurse time spent on the phone justifying their clinical decisions to health insurers diverts critical practice resources away from treating patients. Even then, insurer approvals can take several days. All of this directly interferes with practices' ability to provide timely, high quality patient care," Anders Gilberg, senior vice president of government affairs at MGMA, told HCB News.

Problems with prior authorization include submitting documentation through non-standardized health plan web portals and changing medical necessity requirements and appeals processes. These have repeatedly delayed care and forced providers to hire additional staff to keep up with constant changes in prior authorization regulations.

Another MGMA poll back in May reported a rise in prior authorization requirements since 2020, according to 81% of its respondents. Only 2% said that prior authorization had decreased. "Despite a modest reprieve from certain health plan prior authorization requirements during the first few months of the pandemic, medical groups report a significant spike in prior authorization requirements since 2020," said Gilberg in May. "In addition to the sharp rise in prior authorization demands, practices report increased denials, delayed approvals for care, and constantly changing rules."

An additional challenge is the lack of an efficient payment model. Despite 73% of respondents participating in the Merit-based Incentive Payment System as part of the QPP, 93% say that such payment adjustments do not cover the cost of time and resources spent preparing for and reporting under the program. And 79% say implementing value-based payment policies has only increased burdens. In addition, roughly 90% of respondents say CMS does not provide useful feedback on MIPS to reduce costs or improve clinical outcomes and 80% report there is not an alternative payment model that is clinically relevant to their practice.

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