New AMA initiative launched to improve electronic prior authorization
The AMA announced a new CPT mapping initiative to reduce the administrative burden of prior authorization by making it easier for EHRs to talk to the systems payers use. Today, the clinical information in a physician's EHR and the coding that payers require for authorization often do not connect cleanly, which means staff still spend time manually translating one into the other. The AMA's initiative is designed to close that gap so electronic prior authorization can move faster and with less busywork.
The timing matters. Under a federal rule finalized in 2024, health plans must have electronic prior authorization systems in place by Jan. 1, 2027. The AMA's work is intended to help ensure those systems actually reduce physician workload rather than simply moving it into a new format.
“Modernizing prior authorization requires more than electronic bridges between software applications,” said AMA President Willie Underwood III, MD, MSc, MPH. “It requires trusted, interoperable terminology assets that can support real-world clinical and administrative workflows. By helping bridge SNOMED CT clinical concepts and CPT procedural coding for prior authorization use cases, the AMA aims to support a more seamless, standards-based ecosystem for physicians, hospitals, payers, and patients.”
Over the coming months, the AMA will work with health plans, EHR companies, and other partners to test and refine the approach, with the goal of helping physicians spend less time on administrative hurdles and more time with patients. The maps are being made royalty-free for use in prior authorization.
AMA opposes potential future changes to EHB requirements, citing patient harm and adverse market effects
On July 14, the AMA responded (PDF) to a Centers for Medicare & Medicaid Services (CMS) Request for Information regarding the Essential Health Benefits (EHB) Framework and Typical Employer Plan Standard. The AMA asked the agency to refrain from making changes, explaining that the current framework based on reference plans has been effective, and that altering EHB requirements could lead to adverse selection issues and increase patient out of pocket costs, thereby de-stabilizing the market and worsening individual patient health outcomes.
The AMA expressed particular concern that if EHB protections are redesigned to allow for greater flexibility to manage costs, utilization management tactics like prior authorization and step therapy could become even more rampant. The letter also pointed out that the impact of recently finalized changes to marketplace plan standards as part of the 2027 ACA Payment Parameters rule are yet to be seen, and that additional disruption caused by further EHB changes could have a magnifying effect.
