New AMA policies attempt to revamp prior authorization process
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The AMA said it has adopted new policies regarding the prior authorization process, with its outgoing president stating that maintaining the status quo may cause “life-or-death consequences.”
Bringing the prior authorization process under control has long been a priority of medical organizations, including the American Academy of Family Physicians and the ACP.
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The AMA’s new policies involve the authorizations made during a public health emergency, and peer-to-peer (P2P) conversations between a physician and an insurance company physician employee either during the initial prior authorization process or after a prior authorization has been rejected, according to a press release.
The new policies call for:
- P2P prior authorizations to be made actionable within 24 hours of the conversation;
- reviewing P2P physicians to be clinically proficient in the medical condition or disease under consideration and to possess “knowledge of the current, evidence-based clinical guidelines and novel treatments”;
- P2P reviewers to adhere to evidence-based guidelines “consistent with national medical society guidelines where available and applicable”;
- temporarily suspending all prior authorization requirements and extending existing approvals during a declared public health emergency; and
- health plans to no longer require prior authorizations on “any medically necessary surgical or other invasive procedure related or incidental to the original procedure” if it is completed during an operation or procedure that was already approved or did not need a prior authorization.
An AMA survey conducted this past December showed that 94% of physicians experienced care delays while waiting for a health insurance company to authorize necessary care, 79% reported that patients have called off treatment due to authorization issues with health insurers and 30% said that prior authorization requirements have led to patients experiencing “a serious adverse event.”
Susan R. Bailey, MD, outgoing president of the AMA, pointed to that data as evidence the policies are needed.
“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 in the press release. “Particularly during a public health emergency like COVID-19, unnecessary prior authorizations should not stand between a patient and care they need.”
The policies were adopted during the AMA’s House of Delegates meeting, which is being held virtually this week.
References:
AMA. AMA adopts new policies to rein in burdensome prior authorization policies that delay care. Available at: https://www.ama-assn.org/press-center/press-releases/ama-adopts-new-policies-rein-prior-authorization-burdens. Received June 15, 2021.
AMA. Most physicians had little relief from prior authorization as COVID cases soared. Available at: https://www.ama-assn.org/press-center/press-releases/most-physicians-had-little-relief-prior-authorization-covid-cases. Accessed June 16, 2021.
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Physicians across the United States, myself included, are often burdened and frustrated with the prior authorization process. This is not only anecdotal evidence, but also documented in the literature. The mean annual projected cost per full-time equivalent physician for prior authorization activities ranged from $2,161 to $3,430. These are monetary costs only. The hassle factor and the process of prior authorization also contributes to physician burnout.
The new policies specifically targeting P2P review of prior authorization recently adopted by the AMA is a positive step in the direction of reforming the prior authorization process. Specifically, the policy calling for “temporary suspension of all prior authorization requirements and the extension of existing approvals during a declared public health emergency” will save significant precious time, money and most importantly, lives.
However, more should be done to review the actual prior authorization process itself. Justification made by insurers suggest that prior authorization protects patients; however, that is highly questionable since the experience of many providers suggest they can seriously harm patients. Professional societies and the AMA have been vocal through the years calling for a review and reform of the prior authorization process and more advocacy needs to be done to address this issue.
Reference: Morley CP, et al. J Am Board Fam Med. 2013;doi:10.3122/jabfm.2013.01.120062.
Director, Primary Care Equity, Access and Advocacy, Harvard Medical School
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Reducing administrative burden is a top priority for the AAFP, and we are pleased with the AMA House of Delegates for adopting new policies specifically targeting P2P review of prior authorizations.
The AAFP has long advocated for improvements to the prior authorization process, as well as any other requirement that may delay needed, evidence-based patient care. Family physicians spend half their time on administrative tasks and report that administrative burden is the most pressing problem they face and is the leading cause of physician burnout.
The AAFP calls on policymakers to standardize, automate and reduce the volume of prior authorizations, especially for services that are evidence-based and considered standard of care.
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Thomas L. Ely, DO, FACOFP, FAAFP
The prior authorization process and the delay in access to care has only been exacerbated by the COVID-19 pandemic. The current process is often lengthy and requires physicians and their staff to spend the equivalent of 2 or more days weekly negotiating with insurance companies on procedures that are nearly always eventually approved.
The American Osteopathic Association, which represents more than 151,000 osteopathic physicians and osteopathic medical students, strongly supports the Improving Seniors’ Timely Access to Care Act. This legislation would require a standardized electronic transaction of prior authorization within Medicare Advantage plans, providing much-needed oversight and transparency of health insurance for seniors.
Patients deserve access to the care they need without bureaucratic roadblocks, and physicians deserve to focus on caring for them, rather than filling out paperwork.
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