MGMA: Providers burdened by prior authorization, surprise billing requirements

Wednesday, October 26, 2022

The Medical Group Management Association (MGMA) released its Annual Regulatory Burden Report on October 11. Executives from over 500 group practices said prior authorization and surprise billing requirements were the most burdensome to implement this year.

Eighty-two percent of respondents said prior authorization requirements were “very or extremely burdensome.” Along with inconsistent payer payment policies and decision delays, seeking prior authorizations for routinely approved items or services was a top challenge for providers. Eighty-nine percent of respondents have had to hire additional staff, or redistribute responsibilities among current employees, to complete the additional work brought on by this regulation.

“We have a prior authorization approval rate of 99.87%,” said one respondent. “The fact that we’ve had to hire three additional [full-time employees] this year to manage [prior authorizations] that always get approved is very frustrating and only adds to the cost of medical care.”

This year’s survey revealed providers are having trouble implementing not only old policies but new ones as well. The No Surprises Act, which went into effect January 1, outlawed balance billing for certain out-of-network providers and established several transparency protections. Over four-fifths of respondents said one of those protections, the uninsured or self-pay good faith estimate (GFE) requirement, increased the administrative burden on their practice.

Seventy-eight percent of respondents need additional CMS guidance on GFEs. For providers to fully understand and comply with the No Surprises Act, additional CMS guidance is needed for the following issues:

  • State vs. federal surprise billing requirements (82%)
  • Convening/co-provider requirements (76%)
  • Federal Independent Dispute Resolution process (58%)
  • Continuity of care (53%)
  • Provider directories (38%)

The Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (APM) in the Medicare Quality Payment Program (QPP) are contentious requirements for many providers. Over three-quarters of respondents said Medicare does not offer an Advanced APM that is clinically relevant to their practice and that the move to value-based payment created more headaches.

Along with prior authorization, surprise billing, and the QPP, the following issues burdened providers in 2022:

  • Audits and appeals (64%)
  • Medicare Advantage chart audits (61%)
  • Translation and interpretation requirements (51%)
  • Lack of EHR interoperability (50%)
  • COVID-19 Provider Relief Fund reporting requirements (42%)
  • Medicare and Medicaid credentialing (41%)

“Reducing regulatory requirements that do not improve patient care will assist group practices in focusing on patient care and allow them to invest resources in initiatives that improve healthcare delivery, further clinical priorities, and reduce costs,” said the report.

Overall, 89% of respondents said the regulatory burden on their practice has increased over the last 12 months and 97% believe reducing this burden would allow them to redirect resources to patient care.

“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,” said the report. “MGMA will continue to play a key role in the policy discussion to ensure that medical practices have a voice in Washington.”

Revenue integrity professionals should track staff hours and other resources that go into supporting compliance with requirements such as prior authorization and the No Surprises Act. Look for opportunities to pool resources between departments and encourage cross-functional collaboration to reduce costs. Work with the compliance department to ensure that policies and processes fulfill the requirements and to help spot gaps and overlaps between departments. Finally, consider contacting your representatives and state hospital association to share data on administrative burden.

Editor’s note: Find more NAHRI resources on prior authorization and the No Surprises Act.

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