Medicare Advantage Growth Aggravate Prior Authorization Burdens

Medicare Advantage growth aggravates prior authorization burdens in the several ways. Most medical groups, providing care to patients with Medicare Advantage plans, must comply with more prior authorization requirements.

Increased Administrative Burden: The expansion of MA plans leads to a larger population covered by these plans. As a result, the volume of prior authorization requests increases, placing a heavier administrative burden on healthcare providers. This can lead to additional paperwork, documentation, and communication between healthcare providers and insurance companies, which can be time-consuming and detract from direct patient care.

Lack of Standardization: Different MA plans may have varying prior authorization requirements and criteria, which can create confusion and inconsistencies for healthcare providers. Providers may need to navigate multiple sets of rules and requirements, leading to additional administrative work and potentially delayed care.

Delayed Patient Care: The prior authorization process can be time-consuming, and with the growth of MA plans, the increased volume of requests can lead to delays in obtaining approvals. This can result in delayed care, which can negatively impact patient outcomes and satisfaction.

Increased Costs: The prior authorization process involves significant administrative work, including filling out forms, gathering supporting documentation, and communicating with insurance companies. The increased volume of prior authorization requests resulting from MA growth can lead to higher administrative costs for healthcare providers, which can divert resources away from direct patient care.

Technological Limitations: Some MA plans may require providers to use specific electronic systems or technology to complete prior authorization requests. These systems may be incompatible with the electronic health record systems used by providers, leading to additional administrative work and potential errors.

Efforts to streamline and standardize the prior authorization process can help alleviate some of these burdens. In 2018, the Centers for Medicare and Medicaid Services (CMS) announced changes to the MA program that aimed to reduce the prior authorization burden on providers. These changes included reducing the number of services that require prior authorization, improving communication and transparency with providers, and expanding the use of electronic prior authorization processes.

However, challenges remain, and further efforts are needed to reduce the administrative burden of prior authorizations. Healthcare providers and professional organizations continue to advocate for further standardization, simplification, and streamlining of the prior authorization process.

References:

Centers for Medicare & Medicaid Services. (2018). CMS announces new policy changes for Medicare Advantage and prescription drug benefit programs for contract year 2019.
American Medical Association. (2021). Prior Authorization. https://www.ama-assn.org/practice-management/sustainability/prior-authorization
Prior Authorization in Medicare Advantage, MGMA Federal Policy Resource – MAY 3, 2023
MGMA: Medicare Advantage Growth Exacerbates Prior Authorization Burdens