For mission-driven physicians, bureaucratic roadblocks to patient care can be more than just frustrating. When it comes to delays caused by prior authorization, in fact, those obstacles can even be deadly. That’s why physicians must be involved in technologies to speed up the process.
“We know prior authorization has long been an important topic,” for physicians, said Viet Nguyen, MD, chief standards implementation officer for the health care standards organization HL7 International in a recent “AMA Update” episode on the topic.
“There have been many reports about how burdensome they are,” noted Dr. Nguyen.
In fact, in a December 2024 survey of 1,000 physicians (PDF) that the AMA conducted, 82% reported that prior authorization “can at least sometimes lead to treatment abandonment,” 93% said it has resulted in care delays, and 29% said it has led to a serious adverse event—including death—for a patient. On top of that, 89% of the physicians surveyed said that prior authorization increases physician burnout.
Dr. Nguyen said HL7 is working to include physicians in creating technological solutions to the problems caused by inefficiencies created by prior authorization.
“When I started in informatics, it was all about just standardizing the data,” he said. “And we've gone a long way to doing that over the course of the last 20 years. Now what we want to do is start to standardize the workflow so that the data can help the clinician, and in this particular topic, help them be able to reduce the burden.”
The AMA is fighting to fix prior authorization by challenging insurance companies to eliminate care delays, patient harms and practice hassles.
Speeding up prior authorization
The three aspects of prior authorization, as described by Dr. Nguyen, are:
- Determining whether a treatment or service is covered under a patient’s benefits and whether prior authorization is required.
- Determining and collecting the clinical information or documentation required for approval.
- Submitting the prior authorization request and checking the status for the payer’s decision.
HL7, which stands for Health Level 7, develops health care data standards like its most modern one: Fast Health Care Interoperability Resources (FHIR). In existence for about a decade, FHIR—pronounced “fire”—works like a common language that health care software can use to more easily communicate with other platforms.
In prior authorization, speaking in a common language helps transmit data between physicians and payers to improve communication and avoid dangerous obstacles to care. Dr. Nguyen said without advanced communication, a physician might not realize until after a visit has concluded or a treatment has been ordered that prior authorization is required, for example.
Filling out forms, scheduling additional office visits and waiting for updates on the approval process then create a cascade of downstream delays.
But electronic prior authorization, increasingly used by insurers, physicians and hospitals—and now mandated by the Centers for Medicare & Medicaid Services for government-regulated plans—results in a process of much greater ease and speed. Forms can be provided at the time a treatment is ordered, for example, and all the steps can be managed in one location.
“You don't have to go to a bunch of different portals, checking for the status of prior auths, which can slow down the day and causes burden for the back-office staff,” he said, adding that “we want to reduce the burden for the clinicians. We know that their time in front of their patients is very important and vital. But that time, what we used to call the pajama time, is also important time. And by not being interrupted by the follow-up things during that pajama time, we're reducing burden in a different way.”
Dr. Nguyen said that it’s critical to have feedback from physicians early and often. It’s a lesson first learned after EHRs were created.
The physician perspective “is very important, because the information that they need during a particular workflow, they can share with these standards developers … and the role of the clinician along the way is really to help make the standard better.”
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Visit AMA Advocacy in Action to find out what’s at stake in fixing prior authorization and other advocacy priorities the AMA is actively working on.
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