Regulatory challenges increasing among medical practices

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

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

In the past, MGMA has advocated that policymakers in Washington scale back regulatory burden for medical practices, arguing that these requirements divert time and resources away from delivering patient care. Yet as indicated in this year’s report, the regulatory burden continues to rise.

Of the survey respondents – which were comprised of executives from more than 500 group practices – 89% said the overall regulatory burden on their practice has increased over the past 12 months. Eleven percent said it stayed the same; only 1% said it had decreased.

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

When asked which regulatory issues were the most vexing, the top two answers – by a long shot – were prior authorization and surprise billing and good faith estimate requirements.

WHAT’S THE IMPACT

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

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

In all, 82%of respondents said prior authorization was very or extremely burdensome. Only 2% said it was not burdensome at all. Meanwhile, 95% said their patients have experienced delays or denials for medically necessary care, while 89% said they had to hire or redistribute staff to work on prior authorizations due to the increase in requests.

On the surprise billing front, the  No Surprises Act prohibited balance billing practices for certain out-of-network care and established several new patient transparency protections, such as the uninsured or self-pay good faith estimate process, 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 administrative burden on their practices. Only 26% said they had the technical infrastructure to comply with covening/co-provider requirements that are set to begin January 1, 2023.

Many of the provisions under the No Surprises Act have already taken effect, but confusion and misunderstanding of the requirements remain. The good faith estimate process for uninsured and self-pay patients went into effect on January 1 of this year, yet 78% still require additional guidance from the Centers for Medicare and 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-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). 

In 2022, 73% of respondents are participating in MIPS. It is generally seen as a complex compliance program that focuses on reporting requirements rather than an initiative that furthers high-quality patient care. In fact, 76% of respondents reported that the CMS 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 clinicians and group practices for costs over which they have no control. The group said it regularly hears from members that clinicians and group practices do not understand how CMS evaluates them on MIPS cost measures, and that the lack of actionable, timely information makes this category a “black box” that they have little to no control over.

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

“There is no single approach to APMs that will work for all practices or specialties,” MGMA wrote in the report. “Different specialties are responsible for the provision of different types of care, and thus there is no one-size-fits-all approach to APM design.”

THE LARGER TREND

The House Ways and Means Committee convened a markup session in July regarding a bipartisan bill, “Improving Seniors’ Timely Access to Care Act of 2022,” which seeks to modernize the way Medicare Advantage plans and healthcare providers use prior authorization.

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

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

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

Examples of healthcare services involved in denials that met Medicare coverage rules included advanced imaging services such as MRIs and stays in post-acute facilities, such as inpatient rehabilitation facilities, according to the report.

MAOs denied payments to providers for some services that met both Medicare coverage rules and MAO billing rules, it said. Among the payment requests that MAOs denied, 18% met Medicare coverage rules and MAO billing rules, the report said.
 

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