Prior authorization is a health plan cost-control process that AMA survey research shows leads to delayed and abandoned care, negatively affecting patient outcomes. The average physician practice completes 41 prior authorizations per physician, per week, and doctors and their staff spend nearly two business days a week completing such authorizations.
More than nine in 10 physicians (93%) report care delays while waiting for insurers to authorize necessary care, and 82% say prior authorization can lead to treatment abandonment.
More than one-third (34%) of physicians report that prior authorization has led to a serious adverse event. This includes hospitalization (24%) or disability or even death (8%) for a patient in their care.
Meanwhile, 30% of physicians report that prior authorization criteria are rarely or never evidence-based, with 91% saying prior authorization has a negative impact on patients’ clinical outcomes.
Prior authorization is overused, costly, inefficient, opaque and responsible for patient care delays. That’s why we’re standing up to insurance companies to eliminate care delays, patient harm and practice hassles, and why fixing prior authorization is a critical component of the AMA Recovery Plan for America’s Physicians.
The AMA wants to:
- Cut the overall volume of prior authorizations.
- Increase transparency of requirements.
- Promote automation.
- Ensure timely care for patients.
The AMA supports these reforms:
- Volume reduction solutions such as the elimination of prior authorization requirements for regularly approved care, gold-carding programs, and other exemption programs.
- Establish quick response times (24 hours for urgent, 48 hours for nonurgent care).
- Adverse determinations should be made only by a physician licensed in the state and of the same specialty that typically manages the patient’s condition.
- Prohibit retroactive denials if care is preauthorized.
- Make each prior authorization valid for at least one year, regardless of dose changes. For patients with chronic conditions, the prior authorization should be valid for the length of treatment.
- Require public release of insurers’ prior authorization data by drug, service, and device as it relates to approvals, denials, appeals, wait times and more.
- Prohibiting plans from requiring prior authorizations when patients switch plans before they can get coverage for ongoing care.
Learn about the AMA’s prior-authorization reform initiatives.
The AMA has:
- Successfully pressed the U.S. House of Representatives to pass “The Improving Seniors’ Timely Access to Care Act of 2022,” legislation that will streamline prior authorization processes in Medicare Advantage plans.
- Supported introduction of the "Getting Over Lengthy Delays in Care as Required by Doctors Act of 2022" (GOLD CARD Act), which would exempt physicians meeting a certain approval rate from prior authorization requirements under Medicare Advantage and collaborated with seven states on introduction of state gold carding legislation.
- Helped enact prior-authorization reform laws dozens of states including recently in Michigan, Georgia, Illinois, Kentucky and more.
- Supported introduction of broad prior-authorization reform legislation in New Jersey (PDF) and Washington, D.C. (PDF) in 2022.
The AMA is working to:
- Build momentum for enactment of the “The Improving Seniors’ Timely Access to Care Act of 2022” before the year ends.
- In tandem, continue our strong regulatory advocacy for prior authorization reform by urging the Centers for Medicare & Medicaid Services Administrator to exercise the agency’s existing authority to protect care access for patients receiving government-regulated health benefits and reduce administrative burdens for physician practices. Laying the groundwork for 2023 state reform efforts in across the country.
- Recently adopted AMA policy on prior authorization.
- AMA prior authorization physician survey (PDF).
- Measuring progress in improving prior authorization (PDF).
- AMA model bill: “Ensuring Transparency in Prior Authorization Act” (PDF).
- Prior authorization state law chart (PDF).
- AMA Council on Medical Service reports on AMA policy (PDF) and initiatives on prior authorization (PDF).
- FixPriorAuth.org shows how prior authorization affects patients, physicians and employers and enables you to share your story.
Visit AMA Advocacy in Action to learn more about the advocacy priorities the AMA is actively working on.