Prior authorization is a health plan cost control process by which physicians and other health care providers must qualify for payment coverage by obtaining advance approval from a health plan before a specific service is delivered to the patient.
The AMA believes prior authorization is overused and existing processes present significant administrative and clinical concerns. In order to reduce the harmful impact of these utilization management programs, the AMA has conducted significant research designed to reveal physician concerns over patient care delays, administrative costs and workflow disruptions caused by prior authorization.
Survey data (PDF) of practicing physicians indicate that prior authorization continues to interfere with patient care and can lead to adverse clinical consequences. The survey results also reflect the limited progress (PDF) that health plans have made toward implementing each of five key areas of prior authorization reform.
A qualitative study exploring the fundamental sources of physician satisfaction and dissatisfaction (PDF)—and the effects of administrative work on practices—includes first-hand physician perspectives on how prior authorization impacts physician practices and delivery of care to patients.