What's the news: AMA leaders are “eager to meet” and “serve as a resource” on how to address burdensome prior authorization, AMA executive vice president and CEO James L. Madara, MD, told Mehmet C. Oz, MD, the new administrator of the Centers for Medicare & Medicaid Services (CMS), in a recent letter.
The AMA’s letter came after Dr. Oz told Congress during his confirmation hearing that CMS could, among other things, cut down on the number of prior authorization requests. For example, Dr. Oz said, CMS could require that only 1,000 procedures be subject to the process, drastically lower than the more than 5,000 procedures that require prior authorization today.
“The AMA has a great deal of expertise” on prior authorization, Dr. Madara noted in his letter (PDF) to Dr. Oz. “We have worked extensively for years with specialty and state societies as well as insurers to address this critical issue for patients and physicians.”
The AMA convened and led stakeholders from across the health care industry—including AHIP and the BlueCross BlueShield Association—in developing the 2018 “Consensus Statement on Improving the Prior Authorization Process.” The AMA letter notes that the document includes the following prior authorization improvements that “fully align with the concerns” that Dr. Oz identified in his Senate confirmation hearing.
Volume reduction—Dr. Oz’s proposal to reduce the scope of procedures that must go through prior authorization closely aligns with the AMA’s advocacy efforts. The letter urges Dr. Oz to consider gold-carding programs that waive requirements for clinicians with high prior authorization approval rates.
Improved transparency—The wide variation between plans’ prior authorization requirements and underlying medical policies highlighted during the hearing are big contributors to the current lack of transparency in the process. The AMA wants meaningful transparency that promotes informed decision-making and ensures access to medically necessary care.
Continuity-of-care protections—Dr. Oz noted in his hearing that prior authorization can disrupt patient care; the AMA agrees, with 61% of physicians reporting that prior authorization can clinically destabilize a patient whose condition was previously controlled on a specific treatment plan. The AMA advocates guardrails to prevent care interruptions, including when patients are switching health plans or when their existing plan suddenly requires prior authorization for a treatment that has kept them clinically stable for a long time.
Automation and technology—The AMA agrees with Dr. Oz’s statements that the prior authorization process needs to become a standardized electronic process that is integrated within the EHR workflow. In addition, the AMA noted that use of health care AI in prior authorizations “must be fair, clinically validated, and transparent, with an appropriately qualified physician … meaningfully involved in any potential adverse determination.”
The AMA is fighting to fix prior authorization by challenging insurance companies to eliminate care delays, patient harms and practice hassles.
Why it matters: Prior authorization is a burdensome practice that negatively impacts patients’ health, sometimes even resulting in serious injury or death. Handling the onerous requests also takes physicians away from caring for patients, and it costs practices money when it hires staff to handle requests.
The AMA’s annual survey of 1,000 practicing physicians (PDF) shows that 93% of physicians surveyed in 2024 reported that prior authorization delays patient care; meanwhile, 82% of physicians said the overused practice can lead patients to abandon treatment and 94% linked the process to negative patient clinical outcomes.
“Alarmingly, over one-quarter (29%) of surveyed physicians said that [prior authorization] has led to a serious adverse event, such as hospitalization, disability, or even death, for a patient in their care,” Dr. Madara’s letter to Dr. Oz says. “Beyond this troubling human cost, our survey results reinforce the significant practice burdens and expenses associated with this process: 40 percent of physicians indicated that they have staff who work exclusively on [prior authorization].”
The data from the survey also “raises serious doubts” that prior authorization cuts health care costs, with 88% of physicians reporting that prior authorization leads to higher overall health care resource utilization. Physicians point to additional office visits, emergency department visits and ineffective initial therapies as factors in this increased utilization, the letter explains.
Learn more: Explore the five critical reforms that must be made to prior authorization, how the AMA is pushing for change and what progress is being made, including speeding up payers’ response times and reducing the volume of prior authorizations.
Visit AMA Advocacy in Action to find out what’s at stake in fixing prior authorization and other advocacy priorities the AMA is actively working on.
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