Reforms in prior authorization in Medicare advantage – MGMA calls for action

 Erika Regulsky RCM, RPA
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MGMA Calls for Prior Authorization Reform in Medicare Advantage

The Medical Group Management Association Affiliation (MGMA) has asked CMS to execute policies and regulations that help prior authorization reform and value-based care contracts inside the Medicare Advantage program.

MGMA submitted remarks to CMS Director Chiquita Creeks LaSure because of a solicitation for  Medicare Advantage data. In the letter, the organization focused on the significance of prior authorization reform and value-based contracting.

As per MGMA, prior authorization necessities make critical weight for clinical groups and cause treatment delays for patients. The rising prerequisites and an absence of digitization in payers’ prior authorization processes regularly lead to managerial difficulties for staff.

Why MGMA calls for action?

MGMA thinks that executing changes in the Medicare Advantage program will assist with improving prior authorization and reduces expenses, burden, and care delays.

The organization introduced a few suggestions for CMS. In the first place, CMS ought to distribute the Interoperability and organization for MA Organization, Medicaid and CHIP Managed Care and State Organizations, FFE QHP Guarantors, MIPS Qualified providers, Qualified Clinics, and CAHs proposed rule.

This standard would smooth out prior authorization processes in Medicare Advantage plans whenever settled. In any case, the proposed decision expressed that health plans ought to answer clinical groups in no less than 72 hours for immediate prior authorization and in seven days for a standard prior authorization. MGMA accepts these time spans ought to be shortened.

Second, CMS ought to execute proposals remembered for a past report from the HHS Office of Inspector General (OIG). The report found that Medicare Organizations postponed or denied recipients’ admittance to mind in any event, when the solicitations met Medicare coverage rules. OIG suggested that CMS update review conventions and do whatever it may take to resolve gives that could prompt errors.

MGMA likewise recommended that CMS restore step treatment preclusion in Medicare Advantage plans for Part B drugs. Step treatment expects patients to attempt specific medicines prior to accessing more fitting medicines. As indicated by MGMA, this undermines the provider-patient dynamic cycle and gives health plans more control of patient consideration.

In the end, MGMA has mentioned that CMS increment oversight of Medicare Advantage prior authorization processes and requires straightforwardness of payer prior authorization strategies and layout of evidence-based clinical rules accessible at the point of care.

Value-based contracts in Medicare Advantage programs

Value based contracts in Medicare Advantage programs

The letter additionally featured how CMS could make a move to further develop cooperation in value-based contracts inside the Medicare Advantage program. As opposed to fee-for-service Medicare, MA has the extra adaptability to definitively integrate value-based care principles into payment plans to help the progress to more prominent support in such models. 

MGMA values the organization’s proceeded with center around further developing the MA program and fundamentally assessing how value-based care is a significant apparatus inside MA and can be worked on in future rulemaking. Value-based care contracts differ by practice, specialty and plan and can be mind-boggling for a few clinical groups.

While assessing value-based contracts, practices ought to obviously characterize jobs and obligations, analyze contract performance and execution, survey data, and develop cooperative associations with payers. CMS ought to focus on supporting primary care Medicare Advantage contracts to assist with advancing value-based contracting. Likewise, MGMA suggested the organization gather additional data from Medicare Advantage plans about the application and achievements of significant value-based contracts.

The letter also suggested that CMS offer extra help to smaller and rural clinical groups with respect to value-based contract participation. These offices are more averse to approaching the assets required for value-based contracting and will generally give care to underserved populations who might profit from value-based care.

In recent months more and more updates and regulatory changes have been made to effect that is contradicting the patient and provider livelihood and creating financial burdens. Keeping a track of these guidelines is one of the most important responsibilities of healthcare practice administration and revenue cycle management. The best option to do this is to hire an experienced RCM specialist that can keep your management on the changing regulatory guidelines and policies on a daily bases so that the providers and C-level executives are able to make decisions that is favorable to patient care and reduce provider workplace frustration.

The other most significant yet new method to keep track of these updates is by using Robotic process automation. Creating a self-sustaining RPA bot for verifying all policies and guidelines before starting a billing cycle. These custom-made RPA bots can be used to track CMS and other federal agencies’ policies and maintain a protocol that will find any issues during the time of service or billing.

Whether it be a skilled RCM specialist who tracks these policies and guidelines BillingParasdise and our team of RPA and RCM experts can help hospitals, medical groups, and individual practices to keep keen attention on policy changes. If you are a CFO or a board member of a medical group, this is the right time to inquire about the potential services that can be beneficial.


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I’m a multi-certified revenue cycle management professional and compliance officer with 20+ years of experience. I contribute articles to leading healthcare publications and journals. I am currently working as Senior Transition Manager, in BillingParadise headquartered at Diamond Bar, California. BillingParadise offers Medical Billing Services that intersect perfectly with the EMR/Practice management system you use.BillingParadise has offices in New Jersey, New York, Florida, Georgia, Minnesota, and Texas.

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