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Healthcare practices continue to face overwhelming regulatory challenges, many of which are related to pre-approval and the Medicare Quality Payments Program. In many cases, the burden increases each year.
This is the key point of new research by the Medical Group Management Association, which also reveals that regulatory hurdles are increasingly hindering clinical goals and improving patient outcomes.
In the past, MGMA has advocated for Washington policymakers to reduce the regulatory burden of medical practice, arguing that these requirements take time and resources away from providing patient care. But as this year’s report shows, the regulatory burden continues to grow.
89% of survey respondents, made up of executives from more than 500 group practices, say the overall regulatory burden on their practices has increased in the last 12 months. 11% said they would stay the same. Only 1% said it had decreased.
An overwhelming 97% said that reducing the regulatory burden would allow resources to be reallocated to patient care.
When asked which regulatory issues were the most troublesome, the top two responses (by a wide margin) were prior approval and surprise charges, and the requirement for good faith quotes.
what is the impact
Respondents argued that preapproval delays patient care and increases costs and burdens for health care providers. Payers are required to obtain pre-approval for medical practice before providing certain medical services and prescription drugs. These cost control mechanisms often unnecessarily delay treatment at the expense of patient health and clinical resources, executives argued.
Clinics are faced with pre-approval challenges, such as the issue of manually submitting documents via fax or through the health plan’s own web portal, and the changes in medical requirements and appeals processes required to meet each health plan’s requirements. continue to face growth.
Overall, 82% of respondents said pre-approval was very or very burdensome. Only 2% said it was not a burden at all. On the other hand, 95% said their patients experienced delays or denials of medically necessary care, and 89% said increased demands had required staff to be hired or redeployed to work on previous approvals. said.
On the surprise billing front, the No Surprises Act prohibits certain out-of-network care balance billing practices and imposes several restrictions, including uninsured or self-pay good faith quoting processes, provider directory requirements, and continuity of care. established new patient transparency protections. protection. However, practice has been that this has created a considerable burden since its implementation on January 1st.
Eighty-two percent said uninsured or good faith quote requirements increased the administrative burden of their operations. Only 26% said they have the technical infrastructure in place to comply with the rider/co-provider requirements starting January 1, 2023.
Many of the provisions under the No Surprise Act are already in force, but confusion and misunderstanding of the requirements remains. The good faith quoting process for uninsured out-of-pocket patients went into effect January 1 of this year, but 78% said they needed a referral from their Center for Medicare and Medicaid Services to fully understand this new policy. I still need additional guidance.
In other respects, the Quality Payment Program (QPP) transforms care delivery for Medicare beneficiaries by encouraging the highest quality of care, Merit-Based Incentive Payment Systems (MIPS) and Advanced Alternative Payment Models (APMs). We have created two new reporting channels to:
By 2022, 73% of respondents will participate in MIPS. It is generally seen as a complex compliance program focused on reporting requirements rather than an initiative to promote quality patient care. In fact, 76% of his respondents reported that her CMS implementation of value-based payment reform increased the regulatory burden on practices.
The MGMA said it had long-standing concerns that the MIPS cost measures would unfairly penalize clinicians and group clinics for costs beyond their control. This group found that clinicians and group practices do not understand how the CMS measures them in the MIPS cost measure, and that the lack of actionable and timely information makes this category the category most Or, he said, he regularly hears from members that he’s making it a “black box” that he can’t control at all. .
MGMA also raised concerns with the Medicare and Medicaid Innovation Center in response to recent proposals to create a more streamlined and condensed portfolio of APMs.
“There is no single approach to APM that works for all practices and disciplines,” MGMA wrote in its report. “There is no one-size-fits-all approach to APM design, as different specialties are responsible for providing different types of care.”
the bigger trend
The House Ways and Means Committee on the 2022 Improving Access to Timely Care for Older Adults Act, a bipartisan bill that seeks to modernize the way Medicare Advantage plans and how providers use preapproval A markup session was convened in July.
In 2018, the Office of the Inspector General of the U.S. Department of Health and Human Services expressed concern after an audit revealed that the MA plan had finally approved 75% of the requests that were initially denied.
Health planners and providers agreed in a 2018 Consensus Statement that they could improve on previous approval processes and agree on principles.
An April OIG report found that the Medicare Advantage Organization (MAO) could delay or deny access to services for MA beneficiaries, even though previous approval requests met Medicare coverage rules. It turns out there is.
According to the report, examples of medical services involved in denials that met Medicare coverage rules include advanced imaging services such as MRIs and post-acute facility stays such as inpatient rehabilitation facilities. was included.
MAO refused to pay providers for some services that met both Medicare’s compensation rules and MAO’s billing rules, the report said. Of the payment requests denied by the MAO, 18% met Medicare’s compensation rules and the MAO’s claim rules, the report said.
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