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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.

This section will cover:

Prior Authorization

Surprise Medical Billing


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 supports the implementation of quick response time requirements for submitted prior authorizations.
  • ACOG supports adverse determinations made by licensed, specialty-specific providers familiar with the condition.
  • ACOG does not support retroactive denials of already authorized care.
  • ACOG supports validating authorizations for at least one year and, in the case of chronic conditions, for the length of treatment.
  • ACOG supports public release of payer prior authorization data regarding approvals, denials, appeals, wait times, and other important metrics.
  • ACOG supports validation of prior authorizations of patients transitioning to new health plans for at least 60 days.

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.

Surprise Medical Billing

In December 2020, Congress enacted the Consolidated Appropriations Act of 2021 which included provisions to help patients from surprise bills, including the No Surprises Act (NSA).4 Under these provisions effective January 1, 2022, patients will have new billing protections when getting emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers.5 Overall, ACOG supports protecting patients from receiving unanticipated medical bills from out-of-network providers or others as a result of a coverage gap. However, these protections should be implemented without further burdening, administratively and financially, physicians caring for these patients.

Several components to these regulations are relevant to obstetrician-gynecologists. Many of these components are address in the American Medical Association’s (AMA) tool kit for physicians on implementation of the NSA. The tool kit focuses on three challenges that affected physicians are expected to address in order to be compliant with these new regulations including non-emergency services at in-network facilities, emergency services and post-stabilization care at hospitals or freestanding emergency departments, and good faith estimates for self-pay and uninsured patients. As more guidance on these topics becomes available, the tool kit will be updated accordingly.

Several points continue to be the focus of ACOG’s advocacy around surprise billing, including:

  • Recommend requiring payers involve physicians and/or facilities in the ratesetting and qualifying payment amount (QPA) calculation process prior to services being billed.
  • Recommend payers provide critical information about physician and facility availability, estimates of charges, and prior authorization requirements to patients and providers.
  • Recommend requiring that physicians seeking to initiate the independent dispute resolution (IDR) process are only required to submit the information they have access to and that regulations are modified to place the primary responsibility of submitting the necessary information on the payers.
  • Recommend reevaluation of the presumption that the QPA is the appropriate payment amount and return to the statutory intention of the original legislation.
  • Recommend identification of a more appropriate and efficient method of retrieving good faith estimates (GFEs) for services being furnished for uninsured or self-pay patients.

Further expansion upon these can be seen in ACOG’s comment letters in response to the interim final rules can be found below. CMS has also released informational resources physicians and practices can use to assist them in navigating these new regulations. Additionally, CMS has created a chart for determining whether the federal independent dispute resolution (IDR) process or state law or All-Payer Model Agreement applies for determining the out-of-network (OON) rate utilized to avoid surprise billing.

For any questions or issues related to surprise billing, 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.
  4. Text - H.R.133 - 116th Congress (2019-2020): Consolidated Appropriations Act, 2021. (2020, December 27). https://www.congress.gov/bill/116th-congress/house-bill/133/text
  5. Centers for Medicare and Medicaid Services. Ending Surprise Medical Bills. 2021. https://www.cms.gov/nosurprises/Ending-Surprise-Medical-Bills