'Denials must not be a mystery': AMA adopts prior authorization policies

Key takeaways:

• The AMA adopted new policies on prior authorization reform during its annual House of Delegates meeting.
• They advocate for more legal accountability and denial transparency.

The AMA House of Delegates adopted two new policies aiming to reform prior authorization and the burden it causes patients and physicians.

The new policies “address the need for greater oversight of health insurers’ use of prior authorization controls on patient access to care,” according to a press release. More specifically, they advocate for greater transparency and accountability “against the backdrop of proliferating, onerous prior authorization requirements” that add administrative burdens for physicians as well as delay or deny necessary medical care for their patients.

More legal accountability

Bureaucratic prior authorization policies that conflict with evidence-based practice are inappropriately imposed by health plans, which can jeopardize quality patient care, according to the release. The AMA is now advocating for more legal accountability when this happens.

“Waiting on a health plan to authorize necessary medical treatment is too often a hazard to patient health,” Marilyn Heine, MD, an AMA board member, said in the release. “To protect patient-centered care, the AMA will work to support legal consequences for insurers that harm patients by imposing obstacles and burdens that interfere with medically necessary care.”

The organization additionally noted that it will work to ensure this accountability is not affected by clauses in beneficiary contracts that may place limitations on class action or require pre-dispute arbitration for prior authorization determinations.

Greater transparency

When a health insurer denies access to care, both physicians and patients should be able to understand the justification behind the decision, according to the release. But current denial processes are infamously inconsistent, complex and opaque.

So, the AMA will continue working to ensure prior authorization notifications are provided, along with detailed explanations regarding the reasons behind denials. The new policy outlines some of the basic requirements for information that should be included in prior authorization denial letters, including detailed reasoning behind the denial, any rules the insurance company may cite as part of the denial, information needed to approve the treatment and a list of alternative treatments that are covered.

“Health insurer denials must not be a mystery to patients and physicians,” Heine said. “Without clear information from an insurer on how a denial was determined, patients and physicians are often left to the frustrating guess work of finding a treatment covered by a health plan, resulting in delayed and disrupted care. Transparency in coverage policies needs to be a core value, an essential principle to help patients and physicians make informed choices in a more efficient health care system.”