MGMA Advocating for Prior Authorization Automation & Efficiency

November 12, 2021

The Medical Group Management Association (MGMA) advocates for a concurrent, multi-step approach to reduce the volume and burden of prior authorization requirements from insurance companies. In 2019, prior authorization requirements for medical services and prescription drugs increased 90% according to the MGMA Stat 2019.  

In the current landscape, providers obtaining a prior authorization for medical services or prescription drugs are often completing the task manually by calling, faxing or using a health plan’s proprietary web portal.  With an increase of 90%, this requires practices to expand significant clinical and administrative resources to perform this work.  However, prior authorizations are often interrupted or delayed, often preventing patient care.  In addition, health plans have different medical necessity requirements and submission rules that vary from plan to plan, complicating the process across all payers.  

MGMA is advocating for industry-wide solutions to reduce the burden on providers and are focusing on the following 4 items as their priority:
•    Reduce the overall volume of prior authorizations on medical services and drugs 
•    Waive prior authorization requirements for clinicians in risk-based contracts or alternative payment models, which are inherently designed to facilitate cost-effective care delivery and appropriate utilization 
•    Require transparency of payer prior authorization policy and establish evidence-based clinical guidelines available at the point of care 
•    Increase the automation and efficiency of any remaining prior authorization requirements through adoption of industry-developed electronic standards and operating rules

MGMA plans to work with the provider community, health plans, policymakers and other critical stakeholders to find solutions for requirements and automation for prior authorizations to reduce the burden for providers and their patients.

APS will continue to monitor this topic closely and provide updates when they become available.