5 positive signs on the road to fixing prior authorization

AMA News Wire

5 positive signs on the road to fixing prior authorization

Apr 15, 2024

The time-wasting, care-delaying payer cost-control process known as prior authorization is the bane of physicians’ existence.

According to the most recent AMA survey (PDF) of 1,001 practicing physicians, 89% of respondents said prior authorization had a significant or somewhat negative clinical impact, with 33% reporting that prior authorization had led to a serious adverse event such as a death, hospitalization, disability or permanent bodily damage, or other life-threatening event for a patient in their care.

That is why fixing prior authorization is a critical component of the AMA Recovery Plan for America’s Physicians. Prior authorization is overused, and existing processes present significant administrative and clinical concerns. You can find out how the AMA is tackling prior authorization with research, practice resources and reform resources.

As the physician’s powerful, relentless ally in health care, the AMA’s hard work to ease the burdens of prior authorization is starting to pay off. There is a long way to go yet, but below you will find some positive signs of progress in the AMA’s long-standing, focused effort to fix prior authorization.

1. CMS takes action that will save physicians $15 billion

   1. Under the leadership of Administrator Chiquita Brooks-LaSure, the Centers for Medicare & Medicaid Services (CMS) released a final rule making important reforms to prior authorization to cut patient care delays and electronically streamline the process for physicians. Together, the changes will save physician practices an estimated $15 billion over 10 years.

      As a direct result of advocacy from the AMA and other physician organizations, CMS has taken significant steps toward rightsizing the prior authorization process by addressing both technological and operational requirements. The AMA is grateful that the Biden administration is prioritizing such a critical issue for patients and physicians.

2. A growing number of states are headed in the right direction

   1. In 2023, nine states and the District of Columbia passed legislation that reforms the prior authorization process in their jurisdictions. And the momentum to make changes to cumbersome processes continues to build this year.

      Many bills draw from the AMA’s model legislation (PDF) that includes prior authorization reforms such as: reducing plans’ time to respond to a prior authorization request; ensuring that only a qualified physician is making an adverse determination; prohibiting retroactive denials if the care is preauthorized; and making prior authorization valid for the length of treatment for those with chronic conditions.

3. Insurers are starting to realize they can’t ignore the problem

   1. The country’s No. 1 health insurer, UnitedHealthcare, and another insurance giant—Cigna Healthcare—last year announced tentative steps to reduce the volume of prior authorizations they require.

   2. “The actions taken by UHC and Cigna appear to be a step in the right direction and in line with components of the consensus statement [PDF] to improve the prior authorization process, which was agreed to by insurers in 2018,” said AMA Immediate Past President Jack Resneck, MD, who added that the AMA was “cautiously optimistic” about the changes.     

4. The “gold card” concept is catching on

   1. Texas and other states have addressed prior authorization by passing gold card legislation that exempts physicians from prior authorization for certain procedures and treatments if they have a proven record of delivering appropriate care. Then came a bipartisan congressional bill (H.R. 4968), sponsored by a physician lawmaker, that would exempt doctors from Medicare Advantage plan prior authorization requirements if 90% of the physicians’ prior authorization requests were approved in the preceding 12 months.

   2. Bill co-sponsor Rep. Michael Burgess, MD, told the AMA that the aim of the legislation is to help the vast majority of physicians who are ordering consistent with the medical evidence. For those who do have a 90% or greater track record of having prior authorization requests approved, the bill would mean “you don't need to keep going through this process. ... We're going to trust you that the next case will be just as indicated as the last case."

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5. Patients are speaking up about their experiences

   1. Physicians, practices and health care organizations have long done their best to shield patients from the care delays caused by prior authorization. Yet the harmful practice is being felt by more patients and the consequences are sometimes tragic, as documented in a moving video essay posted in The New York Times’ opinion section, “‘What’s My Life Worth?’ The Big Business of Denying Medical Care.”

   2. Now patient advocacy groups are increasingly joining the effort to effect meaningful reforms for patients and physicians. These organizations, too, are collecting data and anecdotes to advocate for patients who have been sharing grievances of how prior authorization is harming their access to care.

   3. “Patients are not always looked at as equal players in this, but they are,” according to Anna Hyde, vice president of advocacy and access for the Arthritis Foundation. “CMS and others often seemed surprised that patients want to be informed and involved. There is not enough understanding of how much time patients put into managing their care.”

Visit the AMA’s FixPriorAuth.org website to learn more about how prior authorization hurts patients, physicians and employers. The AMA wants to know how prior authorization has affected you and is looking for stories from patients and physicians to draw attention to this issue that is affecting the health of so many Americans. Share your story now.