Fixing the onerous and inefficient prior authorization process that health plans and benefit managers use to control their costs—while harming patients and burdening physicians in the process—needs to happen now.
This is why the AMA, our Federation of Medicine partners, and hundreds of health care organizations are speaking with a unified voice to urge Congress to act. And even though prior authorization reform enjoys strong bipartisan support in Congress, the process continues to needlessly delay care and negatively impact clinical outcomes.
The consequences of Congressional inaction on this issue jump out in the AMA’s latest nationwide survey (PDF) of 1,000 physicians from a broad range of practice settings. For example, more than one in four physicians said prior authorization had triggered a serious adverse event (including hospitalization, permanent impairment or even death) in a patient under their care. Further, 82% of physicians surveyed reported that patients had abandoned treatment altogether due to prior authorization issues with insurers, while 94% said poorer clinical outcomes were directly linked to prior authorization.
Impact on physicians
Overly burdensome prior authorization processes take a heavy toll on physicians as well. The AMA’s 2024 survey indicated that responding physicians completed an average of 39 prior authorization requests each week, with 75% of those surveyed reporting that denials had risen, in many cases significantly, over the past five years. On average, handling those requests for a single physician requires 13 hours of physician and staff time each week, reducing valuable time that could otherwise be spent directly on patient care.
The result? Higher physician burnout, lower practice productivity tied to diverted time and resources, and higher practice costs. The wasteful roadblocks to treatment payers place in front of physicians are even greater when projected across the entire health care system. That’s because resources are diverted to ineffective initial treatments (i.e., inappropriate step-therapy requirements), and higher overall utilization results when patients seek emergency care or are hospitalized when their health worsens due to prior authorization denials.
Such denials are routinely issued without explanation or justification, by anonymous reviewers with unknown credentials, and with no guidance on alternative treatment options. Physicians and their patients are left in the dark, with adverse outcomes for patients too often the result.
The lack of transparency that permeates the prior authorization process is maddening, but even more dangerous is the harm our patients face when treatment is delayed or denied outright. Their conditions worsen, and the results can be devastating when patients decide to abandon the care they need but cannot obtain.
Role of AI in prior authorization
Physicians are also voicing grave concerns that the growing use of unregulated artificial intelligence automation and predictive technologies by health plans will result in an even higher rate of denials, as sound medical judgment is overridden in a process with little to no human involvement.
These concerns are well-founded. Evidence compiled (PDF) by the U.S. Senate Permanent Subcommittee on Investigations shows that the use of automation and predictive technologies has led to higher rates of care denial, suggesting that Medicare Advantage insurers, in particular, are “substituting judgment about medical necessity with a calculation about financial gain.”
Employing automated decision-making to deny more needed care for even more patients is the opposite of the prior authorization reform our nation so badly needs. Physicians must be allowed to bring their training, knowledge of science, and experience to bear in helping patients choose a course of evidence-based treatment through shared decision-making and informed consent—without interference from third-party algorithms and unproven, unsupervised predictive technologies.
I promise you this: The AMA and our Federation of Medicine partners will fight to achieve real and lasting prior authorization reform at the state and federal levels. It is what our patients deserve, what physicians everywhere need, and what our health care system requires. I invite you to share your story and join our fight.
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