MGMA: Prior authorization remains top healthcare challenge

Making progress on automating the prior authorization process is looming as one of the top healthcare information technology policy challenges in the next year.

Facilitating the process of gaining health plans’ approval for medical treatment has grown to be one of the biggest frustrations for physicians in group practices, said Robert Tennant, director of health information technology policy for the Medical Group Management Association at its annual conference held this week in New Orleans.

Some 83 percent of respondents to a recent MGMA survey cited prior authorization for medical services as their No. 1 burden, Tennant said. And, another survey suggested that 90 percent of 1,000 physician respondents said the process is getting worse.

The MGMA executive cited data that 182 million prior authorization transactions occurred in the medical commercial market last year. Of those, 51 percent are handled using manual processes, such as phone calls, fax or mail. Another 36 percent are partially electronic, such as when a group practice queries a health plan’s portal to make a prior authorization inquiry. Only 12 percent are handled using the HIPAA transaction code set, even though “it’s been around for more than a decade,” Tennant noted.


Even if providers and payers communicate using the ANSI X12 278 prior authorization transaction, “it doesn’t do what we need it to do,” he said. “Health plans can reply to one of these electronic transactions with a message that says, ‘Call me.’ “

Prior authorizations are slowing down the process of delivering care to patients, leading potentially to a “tremendous negative impact on patients,” Tennant said.

Two years ago, several large healthcare professional organizations—including the American Hospital Association, America’s Health Insurance Plans, American Medical Association, the Blue Cross and Blue Shield Association and the MGMA—released a consensus statement to improve aspects of the prior authorization process, such as reducing the number of professionals who would be subject to prior authorization.

Those recommendations have gone nowhere, according to Tennant. “The plans did absolutely nothing with the recommendations, and the feeling is that things are actually getting worse.”

Efforts to ease the prior authorization logjam received a boost this year from the introduction of H.R. 3107, called Improving Seniors’ Timely Access to Care Act of 2019. The law would apply only to Medicare Advantage plans, but likely would precipitate broader adoption of electronic prior authorization processes.

Tennant said the bill now has 87 co-sponsors in the House, and the search is on to find a sponsor in the Senate.

Even though the bill was crafted on the professional associations’ consensus statement, health plans are “now backtracking” on their support for provisions of the bill, he added. “We went through this last week with a health plan association line by line,” and the pushback was obvious. “They are pushing back on this as hard as they can. If it gets a Senate sponsor, they will ramp up their efforts (to defeat this). If we can get some traction, we will get a victory on this.”