AMA survey finds prior authorization trends raise patient risks

A survey by the American Medical Association found that prior authorization requirements from insurance companies result in unnecessary risks to patients.

A survey by the American Medical Association found that prior authorization requirements from insurance companies result in unnecessary risks to patients.

In the survey of 1,000 practicing clinicians, more than a quarter of the doctors said prior authorization processes have resulted in serious events for their patients and continue to have a distressing impact on patients and practices.

Doctors have long complained of the frequent insistence of insurers to receive prior authorization forms as a condition of getting reimbursed for treatment. Authorization is typically sought manually or via the electronic HIPAA 278 prior authorization request and response transactions.

Despite calls for reforming the process in the last two years, prior authorization programs and process remain problematic and possibly hazardous, according to AMA.

“The survey continues to illustrate that poorly designed, opaque prior authorizations can pose an unreasonable and costly administrative obstacle to patient-centered care,” says Jack Resneck, Jr., MD, chair of the AMA. “The time is now for insurance companies to work with physicians, not against us, to improve and streamline the prior authorization process so that patients are ensured timely access to the evidence-based, quality healthcare they need.”

On average, 65 percent of surveyed physicians report waiting at least one business day for a prior authorization to go through, and 26 percent said they wait at least three business days. Some 91 percent of the doctors report the lack of a prior authorization result in care delays.

Further, 75 percent of responding physicians report that delays in authorization can lead to treatment abandonment, and 28 percent said prior authorization delays have led to a serious adverse event.

Physicians surveyed by the AMA report that they complete an average of 31 prior authorizations each week, and more than a third of the clinicians have staff who work exclusively on authorizations, according to AMA’s data. Physicians also worry it won’t get better, as nearly 90 percent said prior authorization burdens have increased during the last five years.

America’s Health Insurance Plans, a trade association for health insurers, said prior authorizations continue to be important, noting that the industry continues to see wide variations in practice, with little to no correlation between spending and quality.

Also See: CAHQ CORE aligns with push to boost prior authorization

“Medical management tools such as prior authorization mean safe care for patients. Health insurance providers have a 360-degree view into how patients use their care and coverage, and we are committed to helping people get better when they’re sick and keeping them healthy when they’ll well,” the organization contends.

“We don’t just pay medical bills—we’re partners in ensuring better health and financial stability for everyone,” AHIP continued. “Just like doctors use scientific evidence to determine the safest and most effective treatments, health insurance providers rely on data and evidence to understand what tools, treatments and technologies best improve patient health. Insurance providers partner with doctors and nurses to identify alternative approaches that have better results and improve outcomes.”

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