Prior Authorization

Who’s making the call on prior authorization?

Sara Berg, MS , News Editor

Governmental regulatory bodies and commercial payers routinely and regularly audit and survey the clinical practice of medicine. This is done to authorize payments made for medical care and services provided to patients in all care settings. It includes verifying and validating the accuracy of medical diagnoses made and used in determining the medical necessity of such care and services.

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But this prior authorization is often performed by clinicians who are not trained, licensed or qualified in making such decisions, notes a resolution presented at the 2023 AMA Interim Meeting.

Fixing prior authorization is a critical component of the AMA Recovery Plan for America’s Physicians.

Prior authorization is overused, and existing processes present significant administrative and clinical concerns. Find out how the AMA is tackling prior authorization with research, practice resources and reform resources.

Who decides what is medical necessary

Making diagnoses or determining medical necessity “are the prerogative and privilege of trained and licensed physicians, nurse practitioners, physician assistants and clinical psychologists,” says the resolution, which was introduced by AMDA—The Society for Post-Acute and Long-Term Care Medicine.

When clinicians who are not trained, licensed and qualified to diagnose medical conditions or determine medical necessity are involved in utilization management, prior authorization, Medicare and Medicaid audits and regulatory surveys, it “creates unnecessary hurdles to safe, timely and equitable practice of clinical medicine,” the resolution says.

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This can also add unnecessary and burdensome work onto the physician’s plate, further contributing to burnout.

To that end, the House of Delegates directed the AMA to “advocate for a change to existing public and private processes including utilization management, prior authorization, Medicare and Medicaid audits, Medicare and state public health surveys of clinical care settings, to only allow physicians with adequate and commensurate training, scope of practice and licensure to determine accuracy of medical diagnoses and assess medical necessity.”

Delegates also directed the AMA to “support favoring the treating physician’s judgment if the reviewing physician is not available” in order to prevent a delay in care.

Read about the other highlights from the 2023 AMA Interim Meeting.