Medicare Advantage: Medical Group Practices’ New Boogeyman

How burdensome do you have to be to replace prior authorization as physicians’ top regulatory burden years running? Pretty burdensome, I’d say. But Medicare Advantage (MA) plans somehow managed to pull that off this year.

That’s my takeaway from the Medical Group Management Association’s 2026 Regulatory Burden Report released earlier this month. The report is based on an MGMA survey of administrators from more than 230 medical group practices across the country.

The MGMA does a regulatory burden survey of its members every year, although I couldn’t find a 2024 or 2025 survey report posted on the MGMA’s website. The latest one is from 2023, and I wrote about it in this post, “No Pandemic Impact to See Here. Doctors Still Hate Prior Authorization.”

The point of that post was that no matter what else was happening in the healthcare world, including a deadly pandemic, medical group practice administrators consistently ranked prior authorization as their No. 1 regulatory burden.

Not so this year. MA plans dislodged prior authorization as group practices’ biggest pain in the ass.

In ranked order, the top four regulatory burdens this year are:

• Audits and appeals
• Prior authorization in MA
• MA denials
• Automatic downcoding in MA

Don’t let that top one fool you.

“The top regulatory burden, audits and appeals, also is commonly associated with MA as practices must comply with mandatory Risk Adjustment Data Validation audits and appeal denied claims,” MGMA said, adding, “MA has quickly become the leading source of administrative burden for medical groups.”

It’s like a March Madness bracket with MA being the No. 1 ranked team in each of the four regions.

The surveyed medical group practice administrators also ranked MA as the type of health insurance plan with the most burdensome prior authorization process, topping commercial plans at No. 2, Medicaid at No. 3 and traditional Medicare at No. 4.

Another thing that caught my eye was “automatic downcoding,” whether that’s by MA plans or other types of insurers. I’ve heard of “upcoding,” where a provider increases its reimbursement by adding or inflating billing codes for services rendered to patients. I guess health insurers are using technology to automatically subtract or deflate those codes and reduce payments to providers. This must be the “battle of the bots” between payers and providers that we’ve been hearing about.

This explains an item on MGMA’s policy agenda. In the report, the MGMA called for “increased oversight of MA plans to ensure prompt payment of accurately coded claims.”

Accuracy is in the eye of the coder, I guess.

Either way, Medicare Advantage has become medical group practices’ new boogeyman. Let’s see how they try to get rid of him.