Practice leaders tell MGMA an approved prior authorization is no guarantee of payment

"Why is it okay that an authorization is not a guarantee of payment?" an attendee asked the government affairs team of the Medical Group Management Association (MGMA). The question came during a town hall Sept. 29 at the MGMA 2026 Annual Conference in San Antonio.

The attendee described sending a payer everything its policy requires, "the 50,000 pieces of information to meet your medical policy," only to have the payer come back later with a postpayment review.

Before opening the floor, Anders Gilberg, MGMA's senior vice president of government affairs, cited a finding from the association's 2026 Regulatory Burden Report: 90% of practices said their prior authorization burden grew over the past year. The report drew on survey responses from executives at more than 230 group practices.

Gilberg asked whether anyone in the room had found prior authorization easier. No one had.

Related content: The top 10 regulatory burdens for medical practices in 2026

Denied after approval

An attendee who works in oncology in Portland, Oregon, said her staff can spend an hour or two on hold trying to reach someone at an insurer. Approvals for time-sensitive care are slow, she said. "Waiting two weeks to find out if you're going to get an authorization for a patient who needs to start chemo is too long," she said.

Claims denied despite an approved authorization come back looking like the practice's mistake, she said. "The way the denials work is it's coded as though we did something wrong," she said. Her billing entity then tells leadership to fix the front end, and staff members have to review each claim to find that the authorization was in place. Some services take a year or more to be paid even with an authorization and a patient-specific carve-out contract, she said.

She said insurers should face the scrutiny practices do. "Let's start penalizing them. Let's do fraud, waste and abuse on them," she said.

Another attendee said a surgical oncologist at the organization had to estimate a specimen weight before each hysterectomy for a patient with cancer to get the authorization approved. "We all know you fight to get those authorizations in, and it's still not a guarantee of payment," the attendee said.

An attendee who left Texas in December for a rural health organization in Colorado described a patient who retired from Texas state employment. Medicare Advantage was the only coverage the patient could afford, she said. A surgery authorized one year was denied the next. The patient hired an Austin attorney who specializes in disputes with payers, and the case went before an administrative law judge and on to the Centers for Medicare & Medicaid Services (CMS) before the attorney won. Patients in that position have no recourse other than hiring a lawyer, she said.

Insurers have publicly pledged to reduce prior authorization, Gilberg said, but as some have cut the number of services that require it, MGMA has seen denials climb. "I guess if you just deny it outright, then you don't have to go through the steps," he said, before adding, "obviously I'm kidding."

Where MGMA's federal push stands

"There's no limitations on it," Madison Hynes, M.P.P., an associate director of government affairs at MGMA, said of the utilization management tactics Medicare Advantage plans can use, from prior authorization to downcoding. Several bills introduced in this Congress address fair and prompt payment by Medicare Advantage plans, she said, and "there's a lot of positive energy and momentum in Congress to start reining this in a little bit."

MGMA has also drafted legislation that would prohibit downcoding in Medicare Advantage and is working with congressional staffers to get a version introduced in the next Congress, Hynes said. One version is a flat ban that covers automatic downcoding and includes language on algorithms and artificial intelligence. A fallback version would let a plan downcode only after proving a clinician had upcoded a set percentage of claims, and only for 90 days, with communication requirements and appeal rights.

An attendee asked whether requiring plans to prove upcoding could open practices to audits extrapolated across their patient populations. If the fallback advances, MGMA would work to keep the burden of proof off practices, Hynes said. Many of the congressional offices she meets with prefer the strict ban, she added.

MGMA's federal work centers on Medicare Advantage because that is where the federal government has jurisdiction, Hynes said. The association hopes the standards spread from there. A payer that builds electronic prior authorization for Medicare Advantage would ideally use it for commercial plans too, she said. She urged practices to work with state legislators on commercial insurance rules.

On electronic prior authorization, Gilberg said rules from the current and previous administrations require insurers to connect with physicians' electronic health records. During a visit, a physician would be able to see what requires prior authorization under the patient's plan, complete a template with supporting clinical information and submit it. MGMA is hearing pushback from payers about the work involved, he said.

CMS is also testing prior authorization in traditional Medicare through its Wasteful and Inappropriate Service Reduction model, which started Jan. 1 in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. Gilberg, who said the model covers 17 services, criticized it for skipping the standardized electronic transmission CMS is developing elsewhere. "It's the same old third parties, portals, fax, all the things that cause all the frustration in staff time," he said.

Gilberg also pointed to prior authorization legislation that has a supermajority of cosponsors but has not passed in a Congress that has passed little. The Improving Seniors' Timely Access to Care Act would require Medicare Advantage plans that use prior authorization to set up an electronic prior authorization program. The House version reached 290 cosponsors in June.

Getting a meeting

An attendee from a Georgia family practice that is also a rural health clinic said lawmakers who are not physicians "just don't live in the same reality that we do." "I've been to D.C. several times to try to lobby on our behalf, and the majority of the times I can't even get somebody to meet with me," the attendee said.

Gilberg suggested inviting lawmakers or their staffs to the practice, and building a relationship with the district office if Washington does not respond. Patients are another source of leverage, he said. "You have a huge patient base," he said, and if a practice faces a hard call such as limiting new Medicare patients, telling patients why can mobilize them.

He also recommended working through the state MGMA affiliate and state medical society, and approaching lawmakers alongside other medical groups in the community. MGMA staff can supply issue papers and call Hill offices on a practice's behalf, he said.

MGMA will package the session's feedback for its advocacy and report back on what it heard in an upcoming issue of its Washington Connection, Gilberg said.