Advocacy in action: Fixing prior authorization

UPDATED . 4 MIN READ

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 45 prior authorizations per physician, per week, and doctors and their staff spend nearly two business days a week completing such authorizations.

AMA Recovery Plan for America’s Physicians

After fighting for physicians during the pandemic, the AMA is taking on the next extraordinary challenge: Renewing the nation’s commitment to physicians.

More than nine in 10 physicians (94%) report care delays while waiting for insurers to authorize necessary care, and 80% say prior authorization can lead to treatment abandonment. 

One-third (33%) of physicians report that prior authorization has led to a serious adverse event. This includes hospitalization (25%) or disability or even death (9%) for a patient in their care.  

Meanwhile, 31% of physicians report that prior authorization criteria are rarely or never evidence-based, with 89% 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: 

  • Secured a rule with the Centers for Medicare & Medicaid Services (CMS) that will lead to an estimated $15 billion in savings for physician practices over 10 years by requiring health plans to offer electronic prior authorization technology that integrates with EHRs.
  • Helped cut patient care delays and improve health plan transparency through the same CMS rule, which reduces the timeframes for prior authorization decisions and requires plans to publicly report prior authorization metrics.
  • Achieved finalization of Centers of Medicare & Medicaid Services (CMS) regulation that right-sizes prior authorization in Medicare Advantage plans by ensuring continuity of care, improving the clinical validity of coverage criteria, increasing transparency of health plans’ processes and reducing care disruptions.
  • Supported recent passage of reform laws in nine states with resources, model legislation, data and coalition building.

The AMA is working to: 

  • Support nearly 20 states in their efforts to enact reform laws in 2023.

Visit AMA Advocacy in Action to learn more about the advocacy priorities the AMA is actively working on.

The AMA works to generate support for policies critical to the nation’s health care system—and we can’t do it without your help. Learn more about ways to get involved with AMA advocacy.

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