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Addressing Prior Authorization Issues

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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 AMA believes that prior authorization is overused and that existing processes are costly, inefficient, opaque and responsible for patient care delays.

The AMA’s multifaceted strategy on this issue includes reform principles, state and federal advocacy, research and practice resources.

Prior Authorization Practice Resources

Since health plans will likely continue to use prior authorization as a resource utilization control for the foreseeable future, the  AMA offers resources to help minimize the impact of prior authorization on practices in the current environment. 

Automation can help reduce the burdens associated with this process. Learn how electronic prior authorization (ePA) technology that integrates with practices’ current electronic prescribing workflows can improve the drug prior authorization process by watching the AMA’s 3-part ePA video series.

Prior Authorization

View each of the 3 videos on YouTube.

The AMA’s Prior Authorization Toolkit provides an overview of the current prior authorization landscape, including the status of ePA adoption; the toolkit also looks ahead to the future of prior authorization and the industry efforts and changes that will create a more efficient process.

Prior Authorization Reform Principles and Consensus Statement

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 and developed 21 principles to improve prior authorization and utilization management programs.

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.

The widespread outreach and advocacy campaign that followed the release of the 21 principles has triggered conversations with the health insurance industry about reducing prior authorization burdens.

These discussions led the AMA, American Hospital Association (AHA), America’s Health Insurance Plans (AHIP), American Pharmacists Association (APhA), BlueCross BlueShield Association (BCBSA) and Medical Group Management Association (MGMA) to develop the Consensus Statement on Improving the Prior Authorization Process.

The AMA believes that this statement represents an important initial step toward meeting the intent of the 21 principles and achieving meaningful reform in prior authorization programs.

Prior Authorization Research

In conjunction with a market research partner, the AMA fielded a web-based, 24-question survey to 1,000 practicing physicians in December 2016.

The national sample comprised 40% primary care and 60% specialty physicians and included only physicians who routinely complete prior authorizations in their practice.

The survey results show the significant burden that prior authorization policies can have on physician practices.

Additional Advocacy

The AMA advocates on multiple fronts, including through model state legislation and testimony to federal advisory councils, to reduce the burdens that prior authorization places on physicians and their staff.

The AMA has model legislation that aims to reduce the administrative burden prior authorizations place on practices and streamline the process to prevent delays in care.

Additionally, the AMA has advocated extensively with the National Committee on Vital and Health Statistics to encourage streamlining the prior authorization process.

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