Prior authorization is a cost-control process requiring health care providers to qualify for payment by obtaining approval from health insurers before performing a service.
The AMA believes that prior authorization is overused and existing processes present significant administrative and clinical concerns.
An AMA-convened workgroup of 17 state and specialty medical societies, national provider associations and patient representatives developed best practices for prior authorization and other utilization management requirements by identifying the most common provider and patient concerns.
The Prior Authorization and Utilization Management Reform Principles are 21 principles that address the following areas:
- Clinical validity
- Continuity of care
- Transparency and fairness
- Timely access and administrative efficiency
- Alternatives and exemptions
See the 100+ additional stakeholders that have signed on in support
The release of the 21 prior authorization reform principles initiated meaningful discussions with the health insurance industry about reducing prior authorization burdens.
These discussions led to the development of the Consensus Statement on Improving the Prior Authorization Process—created by the AMA, American Hospital Association (AHA), America’s Health Insurance Plans (AHIP), American Pharmacists Association (APhA), BlueCross BlueShield Association (BCBSA) and Medical Group Management Association (MGMA).
In December 2019, the AMA surveyed 1,000 practicing physicians regarding their experience with prior authorization. The survey results revealed that prior authorization still poses significant challenges for both physicians and patients, and that many of the reforms agreed to in the Consensus Statement have yet to be widely implemented by health plans.
The AMA has advocated extensively with the National Committee on Vital and Health Statistics to encourage streamlining the prior authorization process.