MGMA calls on CMS to limit prior authorization requirements

The Medical Group Management Association wants to see to Medicare limits for any application of prior authorization by “gold carding” physicians and automating any remaining requirements.

MGMA submitted a response on Wednesday to a request for information from the Centers for Medicare and Medicaid Services on the use of prior authorization in the Medicare program—a process by which health insurers require doctors to first obtain approval before conducting a procedure or prescribing a medication.


“Decreasing access to care for Medicare beneficiaries and increasing provider burden through the imposition of challenging prior authorization requirements is not the appropriate pathway to promoting integrity in the Medicare program,” wrote Anders Gilberg, senior vice president of government affairs at MGMA, to CMS Adminstrator Seema Verma.

“Rather than increasing the use of authorizations, CMS should identify opportunities within the Medicare program to promote program integrity and in the broader healthcare environment to reduce the overall volume of prior authorizations and automate the remainder,” he continued.

While Gilberg states in his letter to Verma that MGMA opposes prior authorization requirements on physicians treating Medicare beneficiaries, if they are to be imposed for certain covered services, the group wants CMS to develop a streamlined process that does not distract from patient care and does not add to practice burden.

“There are a number of opportunities to achieve these goals, including use of real-time or near real-time tools and processes and full transparency regarding what covered services, tests, DME or medications require a prior authorization and what documentation is needed to support a prior authorization or a post-payment Medicare audit,” according to MGMA.

The group describes the current prior authorization process as “cumbersome, heavily reliant on manual processes” and one that “leads directly to delays and denials of care.” According to MGMA, the prior authorization process must be either eliminated or streamlined, including better integrating it with electronic health record systems.

“When prior authorization is required, CMS should make every effort to automate the process,” states MGMA’s letter. “For example, in the area of medications, Medicare should provide, and vendors display, accurate, patient-specific and up-to-date formularies that include any prior authorization requirements and step therapy requirements in EHR systems for purposes that include electronic prescribing and electronic prior authorization.”

In addition, MGMA makes the case that other opportunities exist to streamline prior authorization by leveraging existing electronic transaction standards and mandating a new standard for clinical documentation transmission.

“Increased use of the prior authorization electronic transaction would result in significant savings to both plans and providers,” states the letter. “The current practice for medical groups is to fax, mail or upload to proprietary websites the clinical data necessary to conduct prior authorizations. By leveraging EHR technology, the electronic attachment standard (X12 275) would automate the collection and transmission of clinical data in support of a prior authorization.”