When a patient from Indiana had to be airlifted via helicopter to get lifesaving surgery after cardiac arrest, her insurance company refused to pay the $65,000 bill for the airlift, according to a KARE-TV report. The reason: the service had not been preapproved. “Your plan doesn’t cover this service without it. You are responsible for this amount,” the payer stated.
Another patient in the Chicago suburbs diagnosed with stage 4 colon cancer was unable to get access to a lifesaving immunotherapy because her physician and insurer were entangled in a prior authorization battle over the treatment.
It felt like the payer was assigning a price tag on her recovery, said the patient in a WMAQ-TV news report. She eventually got coverage after a social media campaign and support from her employer.
The AMA's recent survey (PDF) on prior authorization underscores these examples of patient harms. In the nationwide poll of 1,000 practicing physicians—400 working in primary care, the remainder in other physician specialties—93% said prior authorization delays care, and more than one in four (29%) said it led to a serious adverse event for a patient in their care.
More specifically, these shares of physicians said that prior authorization led to:
- A patient’s hospitalization—23%.
- A life-threatening event, or one that required intervention to prevent permanent damage—18%.
- A patient’s disability, permanent bodily damage, congenital anomaly, birth defect or death—8%.
Eighty-two percent reported that prior authorization at least sometimes leads to patients abandoning treatment.
Physicians reported that prior authorization reduces their time with patients and negatively affects their practices. On average, physicians and their staff spend 13 hours a week completing the prior authorization workload for a single physician. Forty percent of physicians employ staff whose primary job is to work on this task.
Three-quarters (75%) of surveyed physicians said prior authorization denials have increased somewhat or significantly over the last five years, with 31% reporting that requests are often or always denied. Given the hassles associated with fighting these denials to get patients necessary care, it is not surprising that 89% of the survey respondents said prior authorization somewhat or significantly increases physician burnout.
Appeals process gobbles physician time
Twenty percent of physicians always appeal cases of adverse payer decisions on prior authorization requests. For those who don’t, 67% reported doubts about an appeal’s success based on their past experiences. Over half said patient care could not wait for the health plan’s approval process, and 55% said they had insufficient resources to file an appeal.
Physicians must often engage in a “peer-to-peer review” with a health plan representative when appealing an adverse health plan prior authorization decision. Nearly two out of three physicians (65%) said they at least sometimes have to participate in such reviews, which can disrupt patient appointments and burden physicians since it involves direct interaction with the health plan representative.
Fifty-six percent of physicians participating in peer-to-peer reviews report that these have increased in the last five years, and only 16% said that the health plan’s “peer” often or always has the appropriate qualifications.
The AMA is fighting to fix prior authorization by challenging insurance companies to eliminate care delays, patient harms and practice hassles. Momentum is also building in the states to place limits on prior authorization.
100 state bills fighting prior authorization
States in 2024 enacted 13 prior authorization reform bills to cut the volume of prior authorization requirements, reduce patient care delays, improve transparency surrounding prior authorization rules and increase prior authorization data reporting.
Stay up to date on prior authorization improvements
Get the latest news on the AMA’s fight to eliminate care delays, patient harm and practice hassles.
The AMA says there are about 100 state bills pending in statehouses across the nation related to prior authorization and utilization management.
Many of them are focused on reducing the volume of prior authorization, either through barring its use for certain drugs or services, reducing the frequency with which plans can require “reauthorization,” or requiring plans to offer gold carding or exemption programs. Other bills would ensure that a physician is “in the loop,” especially when it comes to using AI tools to deny a prior authorization or establishing the qualifications of the reviewer on the health plan’s side.
In addition to fighting on the legislative front to help ensure that technology is an asset to physicians and not a burden, the AMA has developed advocacy principles (PDF) that address the development, deployment and use of health care AI, with particular emphasis on:
- Health care AI oversight.
- When and what to disclose to advance AI transparency.
- Generative AI policies and governance.
- Physician liability for use of AI-enabled technologies.
- AI data privacy and cybersecurity.
- Payer use of AI and automated decision-making systems.
Learn more about the AMA’s challenge to insurance companies to eliminate care delays, patient harms and practice hassles.
