Regulatory Challenges Rise Among Medical Practices


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Medical practices continue to face daunting regulatory challenges, many of them associated with prior authorization and the Medicare Quality Payment Program. In many cases, the burden has increased year after year.

That’s the bottom line of a new survey by the Association of Medical Group Management, which also found that regulatory hurdles are increasingly interfering with clinical goals and improving patient outcomes.

In the past, MGMA has advocated that lawmakers in Washington reduce the regulatory burden on medical practices, arguing that such requirements divert time and resources from patient care. However, as this year’s report indicates, the regulatory burden continues to increase.

Of the respondents, who were made up of executives from more than 500 group practices, 89% said that the overall regulatory burden on their practice has increased in the last 12 months. Eleven percent said it stayed the same; only 1% said it had decreased.

An overwhelming 97% said that a reduction in the regulatory burden would allow them to reallocate resources towards patient care.

When asked which regulatory issues were the most perplexing, the top two responses by far were prior authorization, surprise billing, and good faith estimate requirements.


Respondents argued that prior authorization delays patient care and increases costs and provider burden. Payers require medical practices to obtain prior authorization before providing certain medical services and prescription drugs; these cost-control mechanisms often unnecessarily delay care at the expense of patient health and practice resources, executives said.

Practices continue to face increasing challenges with prior authorization, including issues manually submitting documentation by fax or through the health plan’s proprietary web portal, as well as changing medical necessity requirements and appeals processes to meet requirements of each health plan.

In all, 82% of respondents said prior authorization was very or extremely onerous. Only 2% said it was not a burden at all. Meanwhile, 95% said their patients experienced delays or denials of medically necessary care, while 89% said they had to hire or redeploy staff to work with prior authorizations due to increased requests.

On the surprise billing front, the No Surprises Act prohibited balance billing practices for certain out-of-network care and established several new transparency protections for patients, such as the Good Faith Estimate process without insurance or payment own, provider directory requirements, and continuity of care. protections. But practices say this has created significant burdens since implementation on January 1.

Eighty-two percent say the uninsured or good faith estimate requirement increased the administrative burden on their practices. Only 26% said they have the technical infrastructure to meet the agreement/co-supplier requirements that will begin on January 1, 2023.

Many of the provisions of the No Surprises Act have already gone into effect, but confusion and misunderstanding of the requirements persist. The good faith estimate process for uninsured, self-pay patients went into effect on January 1 of this year; however, 78% still require additional guidance from the Centers for Medicare & Medicaid Services to fully understand this new policy.

On other fronts, the Quality Payment Program (QPP) created two new reporting pathways to transform care delivery for Medicare beneficiaries by incentivizing the highest quality care, the Merit (MIPS) and Advanced Alternative Payment Models (APM).

In 2022, 73% of respondents will participate in MIPS. It is often viewed as a complex compliance program that focuses on reporting requirements rather than an initiative that promotes high-quality patient care. In fact, 76% of respondents reported that CMS’s implementation of value-based payment reforms has increased the regulatory burden on their practice.

MGMA said it had longstanding concerns that MIPS cost measures unfairly penalize doctors and group practices for costs over which they have no control. The group said it regularly hears from members that physicians and group practices don’t understand how CMS rates them on MIPS cost measures, and that a lack of actionable and timely information makes this category a “black box” on which they have little or no control. .

MGMA has also raised concerns with the Center for Medicare & Medicaid Innovation in response to its recent proposal to create a more streamlined and condensed portfolio of APMs.

“There is no single approach to APM that works for all practices or specialties,” MGMA wrote in the report. “Different specialties are responsible for the provision of different types of care, and therefore there is no single approach to APM design.”


The House Ways and Means Committee called a review session in July on a bipartisan bill, “Improving Timely Access to Care for the Elderly Act of 2022,” which seeks to modernize the way that Medicare Advantage plans and health care providers use prior authorization.

In 2018, the U.S. Department of Health and Human Services Office of Inspector General raised concerns after an audit revealed that MA plans ultimately approved 75% of the applications originally denied.

Health plans and providers agreed that the prior authorization process can be improved and agreed on the principles in a 2018 consensus statement.

An April OIG report found that Medicare Advantage Organizations (MAOs) sometimes delayed or denied access to services for MA beneficiaries, even though prior authorization requests met Medicare coverage standards .

According to the report, examples of health care services involved in denials that met Medicare coverage rules included advanced imaging services such as MRIs and stays in acute care facilities such as inpatient rehabilitation facilities.

The MAOs denied payments to providers for some services that met Medicare coverage rules and the MAO’s billing rules, he said. Among the payment requests that the MAO denied, 18% complied with Medicare coverage rules and the MAO’s billing rules, according to the report.

Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com


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