5 strategies to streamline Medicare Advantage prior authorizations in your medical practice
Did you know that medical practices complete 45 prior authorization requests, on average, per week? Physicians and their staff spend an average of almost two business days (14 hours) each week completing these requests, many of which are sent specifically to Medicare Advantage plans that currently enroll 51% of the eligible Medicare population.
Medicare Advantage prior authorizations can be tricky. Although roughly three out of every four Medicare Advantage enrollees are in a plan requiring prior authorization, the actual requirements vary significantly by plan. For example, some Medicare Advantage prior authorization guidelines require prior authorizations across nearly all service categories while others are more limited.
Similarly, some Medicare Advantage prior authorization guidelines follow Medicare coverage rules while others do not. An investigation by the Office of Inspector General and Health and Human Services Department found improper rule application 13% of the time. This same report found that some Medicare Advantage plans also require unnecessary documentation as part of the prior authorization process. Others make human errors or system-driven errors, both of which result in denied payments to providers for services that meet Medicare coverage rules and Medicare Advantage billing rules. While providers appeal only about 11% of Medicare Advantage prior authorization denials, the vast majority (82%) of those appeals are fully or partially overturned.
How medical practices can address Medicare Advantage prior authorizations
Completing prior authorization requests for Medicare Advantage can be time-consuming and administratively draining. That’s why it’s not surprising that some physicians continue to question whether it’s even worthwhile to extend their contracts with these plans. Concerns about beneficiary access to medically necessary care continue to grow. So do concerns about the use of artificial intelligence to deny claims.
Medical practices accepting Medicare Advantage must create streamlined workflows to expedite prior authorizations and promote clean claims. They must also take proactive steps to avoid potential problems. Consider these five strategies:
Strengthen Medicare Advantage contract language. According to the 2024 Medicare Advantage and Part D Final Rule that took effect January 1, 2024, CMS requires Medicare Advantage plans to comply with national coverage determinations, local coverage determinations, and general coverage and benefit conditions included in Traditional Medicare regulations. The agency does, however, permit the use of publicly accessible internal coverage criteria in limited circumstances. It also states Medicare Advantage prior authorization approvals must be valid for as long as medically necessary. Medical practices can include all of this language (and more) in their Medicare Advantage contracts.
Task someone to stay on top of Medicare Advantage prior authorization changes. By signing up for Medicare Advantage newsletters and checking payer portals daily, this individual can easily note changes related to Medicare Advantage prior authorization requirements.
Create plan-specific Medicare Advantage prior authorization lists. These resources can help medical practice staff quickly recognize when prior authorizations are needed and what specific clinical information is required. Similarly, the person charged with staying on top of prior authorization changes can create practice management alerts that prevent staff from being able to schedule and provide certain services in the absence of a requisite prior authorization on file.
Communicate with Medicare Advantage plans through the electronic health record (EHR)—not payer portals. Leverage the EHR to submit clinical information and automate approvals for certain procedures.
Speak up. If Medicare Advantage plans continue to deny prior authorizations, consider contacting your state medical society, the American College of Physicians, or the American Medical Association to provide feedback and inform advocacy work. Seeking help from patients may also be an option in terms of obtaining prior authorization and/or appealing denials. As direct customers, patients themselves may be more successful than providers. Patients can also file a complaint with Medicare. Medicare uses this information to monitor and improve the quality of Medicare Advantage plans.
Looking ahead
If physicians intend to contract with Medicare Advantage plans, they need a proactive approach that includes strengthening contractual language, understanding Medicare Advantage prior authorization requirements, streamlining prior authorization workflows, leveraging EHR-based communications with payers, and more—all in the spirit of decreasing medical practice denials. Learn how edgeMED can help and be sure to check the Healthy Snacks blog for more expert insights, best practices and industry trends.
