Why physicians are frustrated with Medicare Advantage Prior Authorization

Medicare Advantage (MA) plans are increasingly requiring prior authorizations for medical services and procedures, creating a significant administrative burden for physicians and delaying or denying care for patients. According to a recent survey by the American Medical Association (AMA), 91% of physicians reported that MA plans often or always require prior authorization, and 86% said that the burden of prior authorization has increased in the past five years.

The Impact of Prior Authorization on Physicians and Patients

Prior authorization is a process that requires physicians to obtain approval from MA plans before they can provide certain treatments or prescribe certain medications to their patients. The AMA survey found that prior authorization affects a wide range of clinical services, such as imaging, tests, procedures, medications, and durable medical equipment.

The AMA survey also revealed that prior authorization has negative consequences for both physicians and patients. For physicians, prior authorization leads to increased workload, reduced efficiency, and lower satisfaction. The survey reported that physicians and their staff spend an average of 16 hours per week on prior authorization activities, which is equivalent to two full business days. Moreover, 79% of physicians said that prior authorization interferes with their continuity of care, and 74% said that it can have a negative impact on their clinical outcomes.

For patients, prior authorization can cause delays in access to care, disruptions in treatment, and adverse health events. The survey found that 92% of physicians said that prior authorization can delay access to necessary care, and 78% said that it can sometimes, often, or always lead to treatment abandonment. Additionally, 75% of physicians said that prior authorization can sometimes, often, or always result in patients experiencing adverse events such as hospitalization, disability, or death.

The Need for Reforming Prior Authorization Practices

The AMA and other medical organizations have been advocating for reforming prior authorization practices to reduce the burden on physicians and improve patient care. They have proposed several principles and recommendations for improving prior authorization processes, such as:

• Applying clinical validity and evidence-based criteria to prior authorization requirements
• Minimizing the number and scope of services and drugs subject to prior authorization
• Streamlining and standardizing the prior authorization process across MA plans
• Providing transparency and clarity on prior authorization policies and criteria
• Ensuring timely review and approval of prior authorization requests
• Implementing exemptions and exceptions for certain situations and providers
• Reducing the use of retrospective review and denial of payment

The AMA also supports federal legislation that would address some of the issues related to prior authorization in MA plans. The Improving Seniors’ Timely Access to Care Act (H.R. 3107) would establish electronic prior authorization standards, require real-time decisions for certain services, limit the use of retrospective review, and increase oversight and transparency of MA plans’ prior authorization practices.

Prior authorization is a common and growing practice among MA plans that imposes a significant burden on physicians and affects the quality and timeliness of patient care. Physicians need to be aware of the challenges and risks associated with prior authorization, and advocate for reforms that would reduce unnecessary administrative hurdles and ensure appropriate access to care for their patients.