AMA hits insurers for slow progress in cutting prior authorizations

The American Medical Association is increasing pressure on health plans to speed prior authorizations for treatment, in part making better use of IT and standards to do so.

The national organization for physicians released results of a survey of members Tuesday, contending that the health insurance industry has been slow to adopt reforms to the prior authorization process, raising the risks of delayed or disrupted care on patients.

Most health plans are not making meaningful progress on reforming the prior authorization process, executives of the AMA contend, using the survey results as a basis for their demands for action.

In its summary on the results, the AMA offered five suggestions, including accelerating the use of automation and using more analytics to clear away extraneous prior authorization requirements.

Also See: AMA survey finds prior authorization trends raise patient risks

Despite the accelerated shift to value-based care, the prior authorization remains firmly entrenched in the nation’s healthcare delivery system. Receiving authorization to provide care to patients often entails long exchanges of documentation back and forth between providers and payers—without authorization, providers are reluctant to move ahead with treatment, sometimes delaying treatment to patients who would benefit from timely care.

“Physicians follow insurance protocols for prior authorization that require faxing recurring paperwork (and) multiple phone calls; patients’ lives can hang in the balance until health plans decide if needed care will qualify for insurance coverage,” says AMA President Barbara L. McAneny, MD. “In previously released AMA survey results, more than a quarter of physicians reported that insurers’ extended business decision-making process led to serious adverse events for waiting patients, such as a hospitalization or disability. The time is now to fix prior authorization.”



The newly released AMA survey results gauge the progress that health plans have made toward implementing each of the five areas of prior authorization reform outlined in the consensus statement. In sum, plans are lagging in making progress.

The report notes that efforts should be made to speed the adoption of existing national standards for electronic transactions for prior authorizations, according to the consensus statement. However, physicians still report phone and fax are the most commonly used methods for completing prior authorization requirements. Moreover, only 21 percent of physicians report that their electronic health record systems offer electronic prior authorization for prescription medications.

In another example, analytics could be used to help insurers exempt physicians with prescribing patterns that meet evidence-based guidelines or high approval rates from prior authorization, according to the consensus statement. However, only 8 percent of physicians report contracting with health plans that offer programs that exempt providers from prior authorization.

Other suggestions from the consensus report include:

• Insurers should regularly review drugs and services under prior authorization and remove those that that show "low variation in utilization or low prior authorization denial rates." However, most physicians (88 percent) report the number of drugs requiring prior authorization has increased, while 86 percent reported that the number of services needing authorization has risen.

• Insurers should "encourage transparency and easy accessibility of prior authorization requirements, criteria, rationale, and program changes." However, 69 percent of physicians report that it is difficult to determine whether a drug or service requires prior authorization.

• Insurers should “minimize disruptions in needed treatment,” including “minimizing repetitive prior authorization requirements.” However, 85 percent of responding physicians report that prior authorization interferes with continuity of care.

Growing concern that strict utilization management protocols prioritize insurance business decisions over access to timely care has led to the introduction of 84 patient protection bills in 32 states this year. Some bills would remove prior authorization and speed access to lifesaving treatments, such as medications to treat opioid use disorders.