Administrative Burden Advocacy

ACOG advocates on behalf of 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 defined by the American Medical Association (AMA) as a health plan cost-control process by which physicians and other health care professionals must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage.

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.

Some prior authorization facts:

• A 2018 Medicare Advantage Organization Office of the Inspector General report indicated that 1 million preauthorization requests were denied, resulting in a denial rate of 4%.
• In an informal survey ACOG found that prior authorization for services has been noted as one of the top drivers of job dissatisfaction and administrative burden.
• A 2024 AMA survey found a majority of physicians describe the burden associated with prior authorization as high or extremely high.
• Adoption of electronic prior authorization continues to increase, with the 2023 CAQH Index Report noting that 35% of medical plans adopted a fully electronic prior authorization process, a 7%increase from 2022.

ACOG actively advocates on issues related to prior authorization at the state and federal levels. Given its importance to our members, we have detailed key advocacy positions below.

Current ACOG Advocacy Positions on Prior Authorization

• Efforts should be made to ensure safe, seamless record-sharing that protects patients and reduces physician burden, including streamlining efforts to move towards electronic prior authorization.
• Payers should collect the patient’s permission at the time of eligibility determination in order to minimize the number of communication requests that require patient response.
• Denied prior authorizations should be made available to all stakeholders to ensure that patients and physicians can respond accordingly and that necessary care is not delayed.
• The Centers for Medicare and Medicaid Services (CMS) should 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. These programs should be continuously reevaluated to ensure effectiveness and reduce undue burdens on physicians.
• The implementation of quick response time requirements for prior authorization requests and appeals should be prioritized.
• Any adverse determinations and peer-to-peer reviews should be made by licensed, specialty-specific physicians familiar with the condition.
• ACOG does not support retroactive denials of already authorized care.
• CMS should work to ensure that artificial intelligence or other proprietary algorithms do not propagate inequitable treatment or bias during initial prior authorization screenings.
• Authorizations should be validated for at least one year and, in the case of chronic conditions, for the length of treatment.
• Payer data on prior authorizations should be released to the public, including data regarding approvals; denials; appeals; wait times; demographic characteristics including race, ethnicity, disability status, and socioeconomic status; and other important metrics.
• Previously approved prior authorizations of patients transitioning to new health plans should be valid for at least 60 days.

ACOG understands that ob-gyns carry the weight of various responsibilities outside of hands-on clinical care. 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 & 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, patients 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 ob-gyns. Many of these components are address in the 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 rate setting 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.

CMS has released resources for physicians and practices to use for assistance in navigating these regulations, including advocacy toolkits and provider guides. 
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