With physicians and patients continuing to encounter time wasting, clinically dangerous prior authorization (PDF) roadblocks despite insurer pledges to fix the broken system, delegates to the AMA Annual Meeting in Chicago voted to take more steps to hold companies responsible and get patients the care they need.
A recent AMA survey showed that only one in three doctors expect meaningful impact to come from the pledges that insurers made to reform the system, and few physicians said they had seen existing commitments fully implemented. To try to help patients get the timely care they need, the AMA House of Delegates adopted policies that aim to do things such as reduce delays and ensure that there is full transparency when augmented intelligence (AI), also known as artificial intelligence, is used to make decisions.
For starters, delegates said that physicians who provide review for prior authorization decisions for insurance companies are making medical decisions and should be held accountable for those decisions.
Treating physicians are all too familiar with having to go through utilization review and peer-to-peer processes when an insurer questions the course of treatment that they believe is best for a patient. The decisions these reviewing physicians make amount to practicing medicine.
Yet, the reviewers in some cases don’t disclose their identity to the requesting physician, and they aren’t held accountable for their medical decisions.
In an effort to require transparency and accountability when insurers and third-party administrators require utilization review, the AMA will seek legislation or regulation regarding insurance company utilization review to require that:
- The person charged with authorization decisions provide their full name, specialty and National Provider Identifier (NPI), in order to maintain transparency, fulfill the requirements of the Health Insurance Portability and Accountability Act (HIPAA), and allow for accountability should the decision be called into question.
- The reviewing physician be licensed in the appropriate state or jurisdiction and, therefore, accountable to appropriate state medical boards or regulatory authorities for the consequences of these clinically important decisions.
The AMA also modified its managed care medical director liability policy to include prior authorization accountability. The policy, in part, now reads that “medical directors of insurance entities be held accountable and liable for medical decisions regarding contractually covered medical services, including prior authorizations.”
The AMA is fighting to fix prior authorization by challenging insurance companies to eliminate care delays, patient harms and practice hassles.
Reducing care delays in pain care
Inconsistent prior authorization requirements contribute to inequities in patients being able to access evidence-based, nonopioid treatments, and the AMA will advocate to change that.
It’s important because chronic pain—a leading cause of disability and healthcare utilization—affects about 20% of adults in the U.S. and timely care is critical to patients seeing the best possible outcomes, says a resolution introduced by the North American Neuromodulation Society.
Treatments include timely neuromodulation therapies such as peripheral nerve stimulation, spinal cord stimulation and other evidence-based, minimally invasive, nonopioid treatment options for chronic nociceptive and neuropathic pain. Delays are especially harmful for therapies that aim to modulate neural circuits early in the disease, the resolution says.
To help combat these patient-care roadblocks, delegates adopted new policy to:
- Support policies and legislation aimed at reducing administrative delays that negatively impact patient outcomes and access to nonopioid pain care.
- Encourage further research on the impact of insurance-related delays on clinical outcomes, healthcare disparities, and cost-effectiveness in neuromodulation and pain management therapies.
The AMA also will:
- Advocate for the reduction of prior authorization requirements for evidence-based neuromodulation therapies and other non-opioid pain treatments when clinically indicated.
- Work with public and private insurers to ensure that coverage policies for neuromodulation therapies and other nonopioid pain treatments are evidence-based, consistent across payers and minimize administrative barriers to care.
- Advocate for appropriate reimbursement and equitable access to neuromodulation therapies and other evidence-based, nonopioid pain treatments regardless of insurance type or socioeconomic status.
In a separate action, delegates moved to address inappropriate use of prior authorization that can delay timely and appropriate care. They directed the AMA to “advocate against prior authorization denials based solely upon the referring physician or appropriately licensed clinician.”
Regulate use of AI in decisions
The AMA has already engaged in substantial and coordinated action at the federal and state levels to advance oversight, transparency and accountability in how augmented intelligence (AI) is used in prior authorization and coverage determination, but delegates voted to do even more.
The AMA has used comment letters, congressional engagement, technical standards development and more to promote AMA policies surrounding AI, including that AI use be grounded in evidence-based clinical guidelines and that adverse determinations informed by AI go through a review by qualified, specialty-appropriate clinicians who are not incentivized to deny care.
“Despite these efforts, insurer use of AI in UM [utilization management] continues to expand in ways that risk accelerating inappropriate denials, increasing administrative burden and delaying medical necessary care,” says an AMA Board of Trustees report introduced at the AMA Annual Meeting.
In addition to the AMA Board of Trustees continuing to monitor legislative, regulatory and market developments in how payers use AI, the AMA will:
- Advance federal advocacy to ensure that insurer use of AI in prior authorization and claims review is grounded in accurate, up-to-date, evidence-based clinical guidelines derived from national medical specialty societies and peer-reviewed literature.
- Support and seek advancement of federal legislation to promote transparency in Medicare Advantage prior authorization programs, including public reporting of AI and automated decision-making use.
- Advocate for enhanced transparency and accountability in insurer use of AI, including clear disclosure when AI is used in coverage determinations and meaningful access for patients and physicians to the criteria, clinical guidelines and data underlying those determinations.
- Press for safeguards protecting continuity of care, including requirements that previously approved medications not be denied or disrupted based solely on AI-generated recommendations without direct review of the patient record by a qualified clinician.
- Support development and adoption of state-level guardrails that limit reliance on automated systems as the sole basis for medical necessity denials and promote clinician oversight, audit authority and protections against algorithmic discrimination.
- Engage in national AI technical standards discussions to strengthen transparency regarding whether human review occurred in coverage determinations and to facilitate identification of reviewer specialty.
Delegates also directed the AMA to engage Congress, the Centers for Medicare & Medicaid Services and other federal policymakers to strengthen requirements that AI-informed adverse determinations be subject to appeal and to review by a physician:
- Possessing a current and valid nonrestricted license to practice medicine in the state in which the proposed services would be provided.
- Of the same specialty as the physician who manages the medical condition or disease, or provides the healthcare service involved in the request.
- Is not incentivized to deny coverage for care and to ensure that automated systems do not supplant individualized clinical judgment.
Read about the other highlights from the 2026 AMA Annual Meeting.
