Prior Authorization

How prior authorization hamstrings physicians

Andis Robeznieks , Senior News Writer

Prior authorization (PA) is a health plan cost-control process that delays patient care and adds to the heavy administrative load carried by physician offices.

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What your state can do to fix prior authorization run amok

The AMA offers prior-authorization reform resources to help physician advocates address this growing problem in care delivery.

The PA process requires physicians to obtain approval from an insurance company or other payer before they can deliver the prescribed treatment or ordered service their patients need.

Traditionally, health plans have applied prior authorization to newer, expensive services and medications. However, physicians participating in an AMA-sponsored survey reported an increase in the volume of prior authorizations in recent years. This may in part be due to payers placing PA requirements  on  commonly prescribed drugs and services that are neither new nor costly. 

Among the 1,000 practicing physicians participating in the survey, there was near-universal consensus (92 percent) that prior authorization has a negative impact on patients’ clinical outcomes. Sixty-one percent said that negative impact is “significant.” Ninety-two percent also said patients whose care requires PA experience care delays sometimes, often or always.

A new AMA website,, is aimed at both patient and physician audiences. It describes prior authorization’s impact on health care delivery in terms appropriate for both physicians and their patients.

The website has a resource page that includes a PA toolkit, instructions on how to implement electronic prior authorization and a model bill that state legislatures have used as a foundation for new laws reforming the PA process.

“We used the AMA’s model bill as a template to draft Ohio-specific legislation,” Tim Maglione, former Ohio State Medical Association senior director of government relations, said regarding the PA reform law his state passed in 2016.

While the Ohio bill was being discussed, a representative of the Cleveland Clinic testified at a hearing that her institution had 175 “caregivers,” at a cost of $9 million in 2015, dedicated to PA processing.

Repeat faxes had to be sent 430 times each month because the first one wasn’t acted on. And at least 2,000 times a month, five-plus calls had to be made regarding the status of a PA request, the Cleveland Clinic official said.

Patients and physicians are invited to share their own stories on, and several are posted on a story gallery webpage.

“We actually have prior authorizations pending with a total of 119 pages,” said one physician who posted on the website, while a patient asked: “Why do insurance companies have more power over our health than us or our doctors?”

Advocacy efforts have generally focused on state activity, but now there is a reason for concern at the federal level with a proposal to allow Medicare Advantage plans to use step-therapy protocols.

Step therapy is another form of utilization management by payers that requires “patients to try and fail certain treatments before being allowed access to other, potentially more effective treatments,” according to a letter the AMA and 93 other physician organizations sent to Centers for Medicare & Medicaid Services Administrator Seema Verma, MPH.

“While a particular drug or therapy might be generally considered appropriate for a condition, the presence of comorbidities, potential drug-drug interactions, or patient intolerances, for example, may necessitate the selection of an alternative drug as the first course of treatment,” the organizations wrote.

“Step-therapy requirements often fail to allow for such considerations, resulting in delays in getting patients the right treatments at the right time and unnecessary complications in the patient-physician decision-making process,” the letter says.

A New Mexico law restricting the use of step therapy was enacted in May. New Mexico Medical Society Associate Executive Director Annie Jung said the measure’s impact will be felt starting in early 2019.

It has been a “recurring theme” that, at the beginning of each year, parents who switch plans learn their children cannot automatically renew their asthma medication prescriptions, she explained, and step-therapy requirements made these patients “start from ground zero” with their treatment.

“Next January, a lot of parents and pediatricians will be happy,” Jung said.