Prior Authorization

How to make peer-to-peer prior authorization talks more effective

Andis Robeznieks , Senior News Writer

Health plans employ prior authorization (PA) and other forms of utilization management (UM) to control access to certain treatments in a bid to cut health care spending. 

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Peer-to-peer (P2P) discussions between physicians and insurance company doctors are too often just another barrier to care, according to an AMA Council on Medical Service report adopted at the June 2021 AMA Special Meeting.

“The rationale behind P2P is to provide a more transparent PA process that is collaborative and appropriately follows relevant clinical guidelines,” says the report. “However, for many treating physicians, P2P review simply represents another time-consuming and potentially detrimental use of UM by insurance companies.”

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The report also notes that “PA remains a top-of-mind issue for physicians and, as such, deserves substantial AMA attention and resources.”

To that end, the House of Delegates adopted policy to advocate:

  • That P2P prior authorization determinations must be made and actionable at the end of the P2P discussion notwithstanding mitigating circumstances, which would allow for a determination within 24 hours of that discussion.
  • That the reviewing P2P physician must have the clinical expertise to treat the medical condition or disease under review and have knowledge of the current, evidence-based clinical guidelines and novel treatments.
  • That P2P prior authorization reviewers follow evidence-based guidelines consistent with national medical specialty society guidelines where available and applicable.
  • For a reduction in the overall volume of health plans’ PA requirements and urge temporary suspension of all prior authorization requirements and the extension of existing approvals during a declared public health emergency.
  • That health plans must undertake every effort to accommodate the physician’s schedule when requiring P2P prior authorization conversations.
  • That health plans must not require PA on any medically necessary surgical or other invasive procedure related or incidental to the original procedure if it is furnished during the course of an operation or procedure that was already approved or did not require PA.

“Delayed and disruptive treatment due to unnecessary and bureaucratic prior authorization requirements can have life-or-death consequences for patients—something we know from data and surveys of physicians,” said AMA President Susan R. Bailey, MD

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“P2P reviews are another burdensome layer insurers are increasingly using without justification, and the peer reviewers are often unqualified to assess the need for services for a patient for whom they have minimal information and to whom they have never spoken or evaluated,” she said. “Particularly during a public health emergency like COVID-19, unnecessary prior authorizations should not stand between a patient and care they need.”

Read about the other highlights from the June 2021 AMA Special Meeting.