Prior authorization is a health plan cost-control process requiring providers to obtain approval before performing a service to qualify for payment.
Health insurers frequently require prior authorization for pharmaceuticals, durable medical equipment and medical services. The inefficiency and lack of transparency associated with prior authorization cost physician practices time and money. The lengthy processes may also have negative consequences for patient outcomes when treatment is delayed.
The AMA believes that prior authorization is overused and that existing processes are too difficult. Due to its widespread usage and the significant administrative and clinical concerns it can present, the AMA believes that prior authorization is a challenge that needs to be addressed through a multifaceted approach to reduce burdens on physicians and patients.
To improve care access and reduce practice burdens, the AMA convened a workgroup of state and specialty medical societies, national provider associations and patient representatives to create a set of best practices related to prior authorization and other utilization management requirements.
The workgroup identified the most common provider and patient complaints associated with utilization management programs and developed the Prior Authorization and Utilization Management Reform Principles to address these priority concerns. These 21 principles seek to improve prior authorization and utilization management programs by addressing the following broad categories of concern:
- Clinical validity
- Continuity of care
- Transparency and fairness
- Timely access and administrative efficiency
- Alternatives and exemptions
The principles have gained widespread support since their release, with over 100 stakeholder organizations signing on in support of their objectives. These supporting organizations are listed at the end of the resource.