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Administrative Burden Advocacy

The ACOG Health Economics and Practice Management team advocates on behalf of ACOG members with public and private payers to ensure their policies minimize administrative burden.

Prior Authorization

Prior authorization—sometimes referred to as precertification or prior approval—is a health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the payment to qualify for payment coverage.1 In the case of ob-gyn services, often those reviewing requests for the authorization of services are not specialists in obstetrics or gynecology and therefore do not understand the complexities of the conditions or the range of treatments available. Additionally, it is not uncommon for gynecologic surgeons to experience denied claims even with prior authorization due to required changes discovered at the time of surgery.

In the 2018 Medicare Advantage Organization Office of the Inspector General report, it was indicated that 1 million preauthorization requests were denied, resulting in a denial rate of 4%.2 The Council for Affordable Quality Healthcare (CAQH) 2019 CAQH Index found that moving to web portal prior authorizations could save physician offices nationwide approximately $355 million a year.3 These data support the use of electronic prior authorization; however, they also call into question the need of prior authorization the current levels of use.

Current ACOG advocacy positions on prior authorization:

  • ACOG supports any efforts to ensure safe, seamless record-sharing that protects patients and reduces physician burden including the establishment of baseline requirements that reduce administrative burden on physicians and allow equitable access to patient records. Requirements should also require the payers to collect the patient’s permission at the time of eligibility determination, in order to minimize the number of communication requests that require patient response.
  • ACOG strongly recommends that denied prior authorizations are made available to all stakeholders to ensure that patients and physicians can respond and so that necessary care is not delayed.
  • ACOG encourages the Centers for Medicare & Medicaid Services to work with physician specialty societies to identify services that should never require prior authorization.
  • ACOG supports the establishment of gold-carding programs, which set forth parameters in which compliant physicians are relieved of many prior authorization requirements, across all payers.

ACOG understands that ob-gyns carry the weight of various responsibilities outside of hands-on clinical care. In an informal survey, our members shared their rankings of the most important areas ACOG could work to relieve administrative burden, giving valuable insights on where to engage with policymakers and stakeholders. We continue to work with our medical association counterparts across specialties to expand support for minimizing administrative burden of all kinds.

For any questions or issues related to prior authorization or payer policies that are administratively burdensome, please submit your question or experience to the ACOG Payment Policy and Advocacy Portal.

References

  1. American Medical Association. Prior authorization practice resources. https://www.ama-assn.org/practice-management/sustainability/prior-authorization-practice-resources.
  2. US Department of Health and Human Services Office of Inspector General. Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials. 2018.
  3. Council for Affordable Quality Healthcare (CAQH). 2019 CAQH Index. 2020.