Prior Authorization Process Could Threaten Patient Outcomes: AMA Survey

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Prior authorization requirements for needed medical services may put patients’ health and livelihoods at risk, according to a statement issued today by the American Medical Association.

The AMA cites findings from a survey of 1004 practicing physicians in which 51% of providers responding reported that the prior authorization process had interfered with a patient’s job responsibilities. Moreover, more than one third (34%) reported that the process of obtaining prior authorization led to a serious adverse event, hospitalization, disability, or even death. for a patient in their care.

“Health insurance companies entice employers with claims that prior authorization requirements keep health care costs in check, but often these promises obscure the full consequences on an employer’s bottom line or employees’ well-being,” said AMA President Gerald Harmon, MD, in the association statement.

“Benefit plans with excessive authorization controls create serious problems for employers when delayed, denied or abandoned care harms the health of employees and results in missed workdays, lost productivity and other costs.”

Nearly all physicians responding (93%) reported they have had to delay care for patients while waiting for a payer to authorize necessary services, according to the release. A majority (82%) said they have had patients abandon treatment altogether as a result of struggling with insurance authorization delays. Physicians again were nearly unanimous (91%) in their perception that for patients whose treatment requires prior authorization, the impact on clinical outcomes is somewhat or significantly negative. 

When asked how often criteria for prior authorization is based on peer-reviewed, evidence- based studies or guidelines from national medical societies, 30% of respondents said this is rarely or never true. In contrast, according to the survey, 98% of health plans report using exactly this type of information to create their prior authorization programs.

Only 1% of respondents said that prior authorizations have had a somewhat or significantly positive impact patient clinical outcomes.

According to the AMA statement, there has been little progress made by large health plans on an agreement made several years ago to initiate a series of improvements to the prior authorization process.

“Now is the time for employers to demand transparency from health plans on the growing impact of prior authorization programs on the health of their workforce,” said Harmon.

Here are some tips physicians can use to limit the impact of prior authorizations on their practice:

• Assign a staff member to each payer. This person can become an expert on the payers for which they are responsible, learning their specific expectations and what to avoid. They can also build relationships with their counterparts at the payer, which may help expedite claims and appeals. This person should also create a basic guidebook for each payer that others can follow if needed.
• Maximize the use of technology. Most payers offer online forms for the prior authorization process and some EHRs integrate directly with payer formularies. The more a practice can use these online forms, the more quickly an authorization can be obtained. In many cases, any missing information will be flagged before submission.
• Document all treatment decisions and back them up with evidence-based practices. Payer justification for prior authorizations is that physicians are not always following the latest evidence-based practices, so ensure all treatment decisions are based on the latest guidelines. If a prescription is not following the formulary, make sure all information as to why it is not included in the prior authorization form.