Prior authorization and other regulatory burdens have increased since last year, practices tell MGMA

Nine in 10 polled medical practices say their regulatory burden has increased over the past year with prior authorization, audits and appeals, the Medicare Quality Payment Program (QPP) and requirements around surprise billing and good faith estimates headlining physicians’ complaints.

That’s the latest from the Medical Group Management Association’s (MGMA’s) annual regulatory burden report (PDF), which surveyed the heads of more than 350 group practices to detail the key regulatory headaches they face.

The uptick in regulatory burden reported by most of the practices is diverting time and resources away from patients, the practices told MGMA. Ninety-seven percent of respondents said reducing regulatory burden would allow them to reallocate resources to patient care, according to the report, while 77% said their regulatory and administrative burden is impacting and will impact Medicare patient access.

When polled on specific contributors, prior authorization led the way, with more than 89% of respondents saying it is “very or extremely burdensome” on their practices.

Here, 92% of respondents said their practice had hired or redistributed staff to focus on prior authorization due to an increase in requests, and 97% said their patients have seen delays or denials for “medically necessary care” due to the requirements. Decision delays (88%), prior authorizations for routinely approved services (83%) and inconsistent insurer payment policies (80%) were cited by the practices as “top challenges” complicating the requirements.

Audits and appeals and Medicare QPP followed prior authorization as leading regulatory balls and chains, with 68% and 67%, respectively, categorizing these as “very or extremely burdensome” on their practices.

In regard to the latter, MGMA found that about two-thirds of practices said the move toward value-based payment initiatives in government programs has not been successful to date.

Ninety-four percent said the shift has not lessened their regulatory burden, and 72% said they’ve not seen any resulting quality of care improvements for their patients. Similar to prior years’ surveying, the association wrote that it also heard broad pushback on specific programs like the Merit-based Incentive Payment System and Advanced Alternative Payment Models.

The other major regulatory issues named to practices’ black books were surprise billing and good faith estimate requirements (63% ranked as “very or extremely burdensome”), Medicare Advantage chart audits (62%), lack of electronic health record interoperability (47%), translation and interpretation requirements (42%) and Medicare and Medicaid credentialing (42%), according to the survey report.

“This year’s survey responses demonstrate that there is still much to be done at the federal level to provide regulatory relief for medical groups,” the association wrote. “MGMA will continue to play a key role in the policy discussion to ensure that medical practices have a voice in Washington.”

Among the respondents to MGMA’s latest annual poll, 60% hailed from practices with fewer than 20 physicians, 16% with more than 100 and three quarters were from an independent practice, the association said.

Prior authorization has consistently stood head and shoulders above the other concerns as the top pain point in MGMA’s prior surveys, though this year’s 89% score is a bump over the 81% score reported last year.

The Centers for Medicare & Medicaid Services (CMS) proposed a rule in December 2022 that would require payers and states to streamline prior authorization processes and improve the electronic exchange of health data by 2026, including through the use of a Fast Healthcare Interoperability Resources application programming interface able to handle electronic prior authorization.

Lawmakers and industry applauded CMS’ intent with the proposal but voiced calls for the agency to either go further or iron out conflicting technical provisions before moving forward. CMS has yet to finalize or rescind the proposed rule.